8/25/21 with Linsy.

Today is my first day at Topeka VA. I am very excited and nervous because everything is new to me. I spent approximately two hours at HR to get my student and set up access to the electronic medical records. Linsy had me observing her today.  She had one of the nurses took me for a tour of the buildings.

Interesting encounter today. One of the patients we saw today was a female veteran who came to the office with her wife of 20 plus years. They were happily married but had not lived in the same house. Although they lived in different homes, they still saw each other daily. Linsy helped them made an appointment with the pharmacist in the VA to go over her medication history. Any VA providers have not seen this female veteran over the last ten years, and this has made it harder for Linsy to get all her information in one hour as she has complicated medical issues.  Linsy told them that she might not finish her assessment in one visit due to the time limit. Linsy told me that the standard time for a new patient is one hour, and sometimes it takes more than one appointment before she starts the patient on medications. My goal is to read the handouts regarding the services that the VA hospital offers.

 

• It is so easy to forget asking certain questions so I will write those down on a piece of paper and keep them at hand while conducting interviews. things I tend to forget are pregnancy, medical histories and immunizations.
• Documenting promptly or write things down as our memories are not always reliable.

By midterm, I will be able to recall from memory the starting dose for the 5 most commonly
prescribed ADHD medications at my clinical site. 

9/1/21 with Linsy

Today was a busy day.  Linsy had me interviewing a couple patients with her supervision. The interviews went well but struggled with their computer system.

I tried to call HR and ask if they provide any computer training and the answer I got was to have my preceptor show me. However, Linsy has tried to ask her supervisor to get a room with the computer so I can use it, but we have not heard anything back yet. She also asked whether she could block some time to teach me, but they told her "no" due to the shortage of providers. So today, she had me using her coworker's computer for a short time to look up patients' information. Her friend uses a particular mouse that is so new to me, and I had to use my coping skills not to let my anxiety go up so high.

Interesting patient encounter

One of the patients we saw was an elderly gentleman with a history of PTSD secondary to being in the battle fields and from his last job before retirement.  He was working for a VA hospital in the security department.  He had to handle a traumatic event as one of the head of the security officer. It was a completed suicide.  He refused to go to Linsy's office because of the location remind him of the traumatic event. He prefer to be seen in the exam room by the front desk.  Today, he reported having increased SI and would like to go to an inpatient unit. However, he did not want to be admitted to the local VA, and another VA is too far for his wife to visit him.  His wife was there with him and continued to convince him to stay at the local VA hospital.  We provided reflective listening and emotional validation, and the patient agreed to go to the local VA PTSD unit. In addition, I assessed his mental status using MMSN, and he scored at 24/30.

• Wellbutrin is contraindicated for patients with a history of bulimia or anorexia nervosa, alcohol withdrawal because it decreases seizure threshold.
• Amitriptyline should not be stopped abruptly. TCA’s like amitriptyline can be deadly in the presence of overdose. For patients with severe depression and SI, only give a few days’ supplies. Overdosing of TCAs can result in hyperactivity of the central nervous system and seizures.

By the midterm, I will be able to recall from memory about the starting dose for different SSRIs and SNRIs.

9/7/21 WITH Amber Johnson

Today was my first clinical day at Valeo.  I was a little concerned about how this clinical experience would turn out because my preceptor, Amber, has never precepted an APRN student before. She was appointed to me by her director, whom I had asked to be my preceptor a year ago.  

Amber was supportive of me. She showed me around in the building and answered a lot of my questions patiently. Valeo is a community mental health center, and it receives grants and incentives from the government and other donations. It also provides services to patients with or without medical insurance. It has a variety of services such as crisis houses, rehab units, temporary housing. It provides services including medical care, psychiatry care, psychotherapy care and case management care.   

I was introduced to several APRNs that work in the same building. One of the APRNs, Deb, runs the Clozaril clinic. With Amber's permission, I asked Deb if she would let me shadow her for a few hours soon, and she agreed.

Their charge nurse Angela asked me when I would be ready to see patients, and I told her that I am comfortable talking to patients, but I need my preceptor to be there with me.  Angela says she understands. 

Interesting patient encounter

One of the patients we saw was a female Pt in her mid-fifties who presented with severe anxiety. She has a psychiatric history of PTSD, Panic disorder, GAD and MDD. She stated that she ran out of benzodiazepine and has been very anxious.  She said her PCP, who used to prescribing her benzos, has fired her recently. Pt said she had recent Gastric Sleeve surgery in Las Vegas (without telling her doctor) and developed an infection in which she was in septic shock. When her doctor found out, he was upset and would not schedule her for another appointment (I wonder if this was a patient abandonment issue). Amber listened to her, validated her feelings and prescribed Xanax for the patient.  Afterward, I asked Amber’s rationale for prescribing Xanax for the patient. She explained that the patient was in great distress and that it was appropriate to prescribe Xanax and gradually taper the medication off when she is more stable.

• Sudden discontinuation of benzos can be life-threatening due to risk of seizing; other common withdrawal symptoms are sleep issues, irritability, anxiety, panic attacks, hand tremor, sweating, difficulty concentrating, palpitations, headaches, etc.
• Cyproheptadine is a serotonin antagonist used in serotonin syndrome

By midterm, I will be able to recall from memory about the first generation antipsychotic medications with their starting doses and their main adverse effects.

9/8/21 with Linsy

Today I interviewed three patients with Linsy’s supervision.  So far, she liked my interviews and my notes. 

One of the interesting patients I saw today was an elderly veteran in his mid-seventies who has suffered from PTSD, depression and anxiety. Linsy told me that this veterans was in the Vietnam War. The interview went well with him. I tried to show my respect and called him "Sir" and "Thank you for your service." He is charming and humorous and makes us laugh. He is taking her medications as scheduled, and he has been actively participating in groups that were offered at the VA hospital.  

• Make sure to ask a female about whether they are pregnant or plans to get pregnant because this is very important due to potential harm to the fetus.
• Pt who are resistant to multiple psychotropic medications may recommend the patient to do gene testing.

By midterm, I will be able to recall from memory about 2^nd generation antipsychotic medications, their starting dose and their main adverse effects.

9/14/21 with Amber Johnson

Today was a good day.  I was given keys to the building and to one of the offices. I interviewed a couple of Pts today and participated in their monthly APRN meeting.   

Interesting patient encounter

The patient is seen via secure video chat.  This is a female patient in her early twenties who has a psychiatric history of MDD and GAD. She said she has not been doing well due to stress at work. She says she works as a KVC case manager.  She states that she has been threatened by this young boy who is under KCV custody because she allowed him to use her phone.  This boy told her that he was going to report her for letting him use her phone to get on social media.  She said she has been more depressed lately. She said that she used to take Lexapro and Adderall, which has helped her mood and concentration. Amber prescribed her Lexapro and Adderall. Amber communicated her treatment plan with the patient's regular APRN. However, this APRN got upset because she did not want her patient to take Adderall. Amber said she has not sent the Adderall to the pharmacy, and will call the patient to explain that her regular APRN did not agree with the treatment plan. Amber told me that normal she avoids seeing other APRN's patient. But this patient needed to be seen sooner and her regular APRN has no time to see her.

• Wernicke aphasia means not understanding what others are saying; their speech tends to be wordy and nonsensical.
• Broca aphasia means the person understands what others are saying but can only talk with broken speech.

By midterm, I will be able to recall from memory about the function of dopamine in the brain and its pathways.

9/21/21 with Amber

Today was a busy day. They had scheduled four new patients for me. Amber told me that four new patients were too much, and she did not understand the rationale behind it. In addition, she was scheduled to see two follow-ups during the time that I would be seeing my new patients (which did not make sense because she has to be present when I see patients).

Interesting encounter,

One of the patients we saw today was a younger male who came in to be evaluated. He appeared manic with pressured speech, racing thoughts, mood elevation, grandiose, mood elevated and laughed a lot over minor things. He told us that he had been in and out of jail due to risky behaviors, such as using/selling drugs.  He told us that he was in prison for a few months and was seen by a provider who prescribed Lamictal for him.  He told us that the Lamictal had helped his mood from going dramatic swings. He said that he has no insurance and was hoping he could get some assistance from Valeo. We collaborated on medications selections and co-educated the patients about their diagnosis and medications while made me feel good by the end of the day. 

• Lamictal is a good medication for bipolar disorder but the SE including Steven’s Johnson syndrome. Patient educations including medications adherence and sighs and symptoms of skin rash.
• Treating bipolar with Lamictal, one should follow the recommendations. at first two weeks take 25 mg a day, at week 3 take 50 mg per day, at week 5 take 100 mg day, at week 6 take 200 mg(max dose) day. 

By midterm, I will be able to recall from memory about MOAIs, including starting doses, adverse effects and patient teaching.

9/22/21 with Linsy

Today was my third day and last day doing clinical with Linsy. I am glad I got a chance to do my clinical at the VA but I did not feel that I am getting enough one on one time with Linsy because she has been so busy doing current job as well as transitioning to a new position within the VA.

Interesting patient encounter.

One of the patients we saw today was an elderly gentleman in his seventies with a psychiatric diagnose of PTSD, Schizophrenia, anxiety, history of substance use. Linsy told me that he was not doing well when she first started to see him.  The patient has been getting better with medication management and services provided by the VA.  Linsy said it made her feel good to see her patients doing well.  However, she has observed that some veterans were afraid to report symptom improvement, fearing losing their benefits.  

• Delirium can often present with sever psychotic symptoms and agitation and the drug of choice are the antipsychotics.
• Drug induced cholestasis can occur with phenothiazine’s, oral contraceptive pill, erythromycins, tricyclic antidepressants, sulfonamides, sulfonylureas, gold and penicillamine.

By midterm, I will be able to recall from memory about TCAs, including starting doses, adverse effects and patient teaching.

10/5/21 with Dr. Shah

Today I started my clinical with Dr. Shah doing hospital psychiatric consults.  Dr. Shah initiated this psychiatric consult/intervention team four years ago after Stormont Vail Health closed their geriatric psych unit.  His consult team has two psychiatrists, three APRN’s, three therapists, and two scribes.  The psych consult team function as emergency behavioral issues, patients with history of mental illness, acute trauma, and patient with altered mental status.

On interesting patient encounter today

There was a 19-year-old male who had a MVA and was disoriented and paranoid.  He has been yelling repeatedly “The cops are going to kill me.” He was under a lot of distress caused by his paranoia. Psych consult physician was paged to see this patient.  Dr. shah attempt to talk to the patient but the patient did not calm down. The patient was given Haldol 5 mg IV, 5mg IM plus 2 mg of Ativan. The patient went to sleep soon after that. 

• Haldol is useful for agitation, psychotic symptoms, but it also used as antiemetic medication.
• The onset of Dementia is gradual, but delirium is rapid onset with underline medical issues.

By midterm, I will be able to recall from memory about MOAIs, including starting doses, adverse effects and patient teaching.

10/12/21 with Dr. Shah

Doing psych consult again at hospital.  Most of our patients today were elderly patients consulting for brain injuries due to recent falls. 

Interesting patient encounter.

We did a MOCA on a male patient in his 60’s. He was able to carry on conversation. However, he only scored 7 on the MOCA.  We were very surprised about the result.  He had severe short term memory loss, and this has affected his ability to make informed decision.  The patients had a brain tumor but opted out surgery.  The nurse is going to start a petition for the judge to determine his capacity of making decisions for himself. 

• One of the many strategies of having a good conversation with the aging veterans is to ask stories about when they were younger.
• Precedex is had anxiolytic, sedative, and some analgesic effects.  It is indicated for initial sedative on of mechanically ventilated patient for up to 24 hours. It may reduce the duration of mechanical ventilation and ICU stay—adverse effects including hypotension, hypertension, and bradycardia.

Goal:  By the end to the semester, I will be able to memorize at least 20 medications on BEER’s list.

 

10/13/21 with Dr. Masterson

Today is a busy day.  I did several interviews by myself with Dr. Masterson’s supervision and feedbacks.  

Interesting patient encounter

There was a young female college student admitted due to suicide thoughts and rapid decline of mood. It came to find out that she has been taking prednisone for a skin rash, but this has caused her manic like symptoms, such as racing thoughts, pressured speech, distractibility and impulsivity. 

By midterm, I will be able to recall from memory about the difference between ADHD, IED, Conduct Disorder, ODD.

 

10/14/21 with Dr. Masterson

Today is another busy day and I feel like I’ve learned a lot.

Interesting patient encounters:

One of the female pt with borderline personality disorder came to me and told me that one of the staff nurses were so mean to her that she does not want the nurse to walk her out of the unit as she is discharging. She asked me to walk her out. Immediately, I realized that her behaviors as splitting me and the other nurse. I told her that I was sorry, but I didn’t think it was appropriate for me to do so. She told me that she understood. I was glad I did not say yes to her request.  

• first generation antihistamines are to avoid using among elderly due to risk of urine retention, sedation, confusion, constipation and so on.
• Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate

By midterm, I will be able to recall from memory about mood stabilizers, including starting doses, adverse effects and patient teaching.

 

10/15/21 with Dr. Masterson

Today is a good day.

Interest patient encounter. This is a middle-aged gentlemen admitted for SI due to going through a divorce.  I was able to provide therapy for him using reflective listening and emotional validation. He told me that his wife had narcissistic personality disorder and he was emotionally abused by her. He told me that they have been married for 17 years but he had been very sad about the divorce.  I was able to emphasize with him because of my past experience. I felt good that I was able to validate his feelings. 

 

• People with bipolar disorder are more likely to seek help when they are depressed than when they are experiencing mania or hypomania. Taking a careful medical history is essential to ensure that bipolar disorder is not mistaken for major depression. This is especially important when treating an initial episode of depression as antidepressant medications can trigger a manic episode in people who have an increased chance of having bipolar disorder.
• People with bipolar tends to stop taking their medications when feeling better.  Extensive education should be provided when starting medications.

 

By the midterm, I will be able to explain the signs and symptoms of substance overuse/withdrawal and treatments.

10/19/21 with Dr. Masterson

Today was a very busy day.  Dr. Masterson had to cover the children’s unit because another doctor was on vacation.  I took the initiative to ask a nursing student to observing us interviewing the patient.  

Interesting patient encounter.

We saw a 11-year-old boy with a diagnose of DMDD.   He had a lot of behavior issues including yelling, cussing at peers and staff.  He used vulgar language with Dr. Masterson and showed him the middle finger. He was restricted to the unit which prevent him from going to the cafeteria and other fun activities. His food tray was brought back for him to eat on the unit.  After a few hours the patient wanted to have a talk

 

• Delta 8 THC is a type of synthetic marijuana. Side effects include vomiting, hallucinations, trouble standing and loss of consciousness.
• Use gender-neutral terms when asking patients regarding their romantic relationships. Instead of saying, do you have a girlfriend, or do you have a boyfriend, ask if you have a special someone, dose your special someone has a preferred pronoun. 

By the end of the semester, I will be able to explain the five major neuro transmitters and their functions.

 

10/20/21 with Dr. Shah

Today is a sad day because one of the patient passed away.

This patient was a nurse in her mid-sixties. Few months ago she was working as an OB nurse at a rural community hospital. She was active in teaching as well as she has over 30 years of experience. She started with some GI issues, that she was not able to have BM for 17 days. She received treatment in one of the hospital but her health kept deteriorating. When she came to this hospital she was confused and not able to talk and at time anxious and combative. After 10 days staying in the hospital, she passed away today.  She lived with her sister who was her DPOA. Her sister told the care team that the patient had told her before she got very sick that she does not want to be put on life support.  We were able to provide emotional support for the family. 

• Having a DPOA is very important and this should be promoted in the community.
• Three commonly used mood stabilizers for bipolar disorder, Lithium, Depakote and carbamazepine are teratogens. The provider should always informed their female patients with child bearing age.

By the end of semester, I will be able to explain the difference between, schizophrenia, schizoaffective disorder, schizoid personality disorder and schizotypal personality disorder.  

 

10/26/21 with Dr. Masterson

Today is another busy day at the adult inpatient.  One of the patient I interviewed was a male in

Interesting patient encounter

One of the female patients we saw today was a very complicated case.  She has tried numerous medications and has not tolerated well. However, she wanted the doctor to start her on Adderall which Dr Masterson was not going to prescribe due to her substance use history and her heart condition. Her main complaint is depression, anxiety, low energy, and poor sleep. She met criteria for BPD and we suggested her to start therapy such as DBT or ECT. However she turned it down. She had mentioned that a very low dose of Seroquel has helped her in the past and agreed to restart it. 

• People with bipolar disorder are more likely to seek help when they are depressed than when they are experiencing mania or hypomania. Taking a careful medical history is essential to ensure that bipolar disorder is not mistaken for major depression. This is especially important when treating an initial episode of depression as antidepressant medications can trigger a manic episode in people who have an increased chance of having bipolar disorder.
• One of the way of testing for pseudo paralysis or conversion disorder is the Hoover test. This is done by having the patient lay supine and place a hand under the calcaneus of the unaffected leg. The patient is instructed to lift the weak leg.   No downward pressure indicates pseudo paralysis or conversion disorder.

By the end of the semester. I will be able to recall from memory about different lab and their function. Such as CBC, CMP, TSH, UA.

 

10/27/2021 with Dr. Masterson

Today is a good day, I can’t wait to finishing up my clinical hours and move on.

Interesting patient encounters.

One of a patient we saw today is young man in the army who is admitted for SI due to going through a divorce with his wife.  His wife called his commander raisin concerns about his safety and he was sent to out psychiatric hospital. However, once he is ready to leave we has to get permission from his commander to discharge him. I also learned that he has to pay monthly living expense to his spouse before the divorce is finalized. 

 

• Creutzfeldt-Jakob disease is a prion disease often associated with transplants of infected corneas. People who are infected with this disease often show rapid cognitive deterioration and death usually occurs within six month.
• High testosterone and low cortisol increase the level of aggression. Whereas, high testosterone and high cortisol lower the level of aggression.

By the end of this semester, I will be able to explain Ericson’s developmental stages. 

 

11/2/21 with Dr. Masterson

Today is my last clinical.  I am so excited and grateful to reach my 500 hours. Interesting patient encounter: One of the patient we saw is a young man who is in his last semester in college came in for SI due to relational problems. He and his ex-girlfriend had separated since July and he blocked her from contacting him. However she found him a few days ago and wanting to get back together. He agreed and later was trying to contact her but found out she had blocked him from reaching her.  We provided a lot of emotional support and recommending him talking to a psychotherapist.  He has also being drinking heavily for the last 4 months and was going withdrawal. It’s a nice review about alcohol use disorder, withdrawal symptoms and interventions.

• Meyers Briggs is an instrument designed to evaluate people and provide descriptive profiles of their personality types and conative style.
• Lithium is a water-soluble substance that passes easily into breast milk, and serum lithium levels in the infant are 1/3 or 1/25 the maternal level.

Progress of my goals

• By midterm, I will be able to recall from memory the starting dose for the 5 most commonly prescribed ADHD medications at my clinical site. (Partially met, will review this by December 1^st).
• By the midterm, I will be able to recall from memory about the starting dose for different SSRIs and SNRIs (met)
• By midterm, I will be able to recall from memory about the first generation antipsychotic medications with their starting doses and their main adverse effects (Partially met, will review this by December 1st).
• By midterm, I will be able to recall from memory about 2^ndgeneration antipsychotic medications, their starting dose and their main adverse effects. (met)
• By midterm, I will be able to recall from memory about the function of dopamine in the brain and its pathways (met).
• By midterm, I will be able to recall from memory about MOAIs, including starting doses, adverse effects and patient teaching (Partially met, will review this by December 1st).
• By midterm, I will be able to recall from memory about TCAs, including starting doses, adverse effects and patient teaching (Partially met, will review this by December 1st).
• By midterm, I will be able to recall from memory about MOAIs, including starting doses, adverse effects and patient teaching (Partially met, will review this by December 1st).
• By the end to the semester, I will be able to memorize at least 20 medications on BEER’s list (Partially met, will review this by December 2nd).
• By midterm, I will be able to recall from memory about the difference between ADHD, IED, and Conduct Disorder, ODD (met).
• By midterm, I will be able to recall from memory about mood stabilizers, including starting doses, adverse effects and patient teaching (met).
• By the midterm, I will be able to explain the signs and symptoms of substance overuse/withdrawal and treatments (met).
• By the end of the semester, I will be able to explain the five major neuro transmitters and their functions (met)
• By the end of semester, I will be able to explain the difference between, schizophrenia, schizoaffective disorder, schizoid personality disorder and schizotypal personality disorder (met)
• By the end of the semester. I will be able to recall from memory about different lab and their function. Such as CBC, CMP, TSH, UA (met)
• By the end of this semester, I will be able to explain Ericson’s developmental stages (met).