File: Another Medical Record Page

This is an excerpt of some entries from 2015/16.

01/18/2016. DANGER TO OTHERS WORKSHEET

DYNAMIC RISK FACTORS

*Severe anxiety symptoms/agitation

*Employment instability

*Impulsivity

*Lack of insight

*Relationship instability

*Lack of social support

STATIC RISK FACTORS

*Low socioeconomic status

*AGGRESSIVE OR DESTRUCTIVE BEHAVIOR

*None

04/20/2015

DYNAMIC RISK FACTORS

*Severe anhedonia

*Severe depression

*Hopelessness

*Suicide ideation or intent

**Suicide plan

STATIC RISK FACTORS

*Mood disorder *History of suicide attempts

AGGRESSIVE OR DESTRUCTIVE BEHAVIORS *Suicide Attempt

*Suicide ideation

4/20/15: Clt endorses SI w/plan to overdose on prescription and OTC medications. Clt reports two aborted suicide attempts earlier this evening, one in which she had 30 Benedryl in her hand ready to take but decided not to and once she had 50 zyprexa in hand. Clt was unable to contract for safety with this writer when the crisis plan was attempted.

9/16/15: Clt endorsers SI w/plan to jump for balcony or crash car. Clt reports that early today she was standing leaning over the balcony for "awhile" contemplating jumping. Clt mentions that she thought she may be able to fly and if not she was aware that this would probably kill her and reports "I was okay with that as long as I don't have to feel like this anymore.

General Behavior: Cooperative.

Speech: Unremarkable

Perception: She currently denies that hallucinations telling her to hurt herself but past E-II records indicate a history of [Me] reporting hallucinations telling her to hurt herself.

Thought Process: Mild paranoia.

Mood: Dysphonic [Dysphoria, "difficult to bear" is a profound state of unease or dissatisfaction. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation."]

Judgement: Fair

Impulse Control: Fair at present

Insight: Poor

Sleep: normal

Appetite: normal

F31.2: Bipolar disorder, current episode manic, severe with psychotic features (Active as of 10/16/2016)

F29: Unspecified psychosis not due to a substance or known physiological condition (Active as of 11/21/2013)

F31.9: Bipolar disorder, unspecified (Active as of 10/29/2014)

F39: Unspecified mood [affective] disorder (Rule out as of 11/21/2013)

DIAGNOSTIC Summary:

4/20/15: Clt's current symptoms and presentation are congruent with previous diagnosis.

9/16/14: Clt's current presentation and symptoms are congruent with previous diagnosis.

11/21/13: Client reports paranoid thinking with delusions. (Thinking people are aliens and endorsing a hx of beliefs that she can fly and that she will not die for long if she kills herself.) Client reports a hx of auditory and visual hallucinations, but none at the moment. Client reports anxiety, related to personal relationships. Client reports that she tried to overdose to kill herself last night with plans to do so again.

10/08/13: Pt presents as preoccupied, possibly7 responding to internal stimuli, hears voices telling her to stab herself, reports some improvement in psychotic symptoms.

10/01/13: Client presents "ramped up" with thoughts of jumping into traffic or "flying off her balcony" w/o specific intent of suicide. She is calm in presentation but she reports that she has felt increasingly "ramped up" over the last 2 weeks. She spoke with her psychiatrist this morning and she recommended she present to PES [Psych ER].