Final

Date: 10/12/2021

1) Describe the day. Overall, what were some of your thoughts and feelings?

Today was the most productive day we have had with the ACT-TAY program. I enjoyed it much more. I really enjoyed several of the encounters with patients who were invested in their health.

2) Describe one interesting patient encounter. What did you learn?

I interviewed one young woman over telehealth today who had been using methamphetamines earlier in the day. I felt her goal was to shock and dismay me with her flagrant disregard for her health. She talked about being “basically a prostitute” and how she was trying to get pregnant while using numerous harmful substances. I did my best to not be lured into the drama. I felt so bad for this patient. She is so young and angry. She on one hand is screaming for help but then is not able to participate. If she was my patient, and I am sure I will have some like this, I do not know what I would do.

3) Identify 2 clinical pearls you learned during the day.

1. Seroquel used for sleep in the elderly can lead to urinary retention due to the predominantly H1 receptor antagonism at low doses, whereas at higher doses the dopamine and serotonin receptors are predominate.
2. Vistaril can cause urinary retention in the elderly.

4) State one specific goal/objective that you will accomplish by the next log review (mid or final).

               Look up ways to work with difficult patients and why they are difficult to begin with.

                              https://ps.psychiatryonline.org/doi/10.1176/ps.2006.57.6.795

" According to several authors ( 10 , 18 , 25 ), almost all difficult patients have a so-called borderline personality organization, which would explain why so many difficult patients have a highly ambivalent relationship with mental health care. People with this kind of personality organization perceive reality accurately yet feel overwhelmed by it, resulting in intense feelings of suffering and a need to seek help. In combination with so-called primitive defenses, such as splitting, idealizing, and projective identification, this lack of a clear self is considered a major source of the often confusing and negative interactions with professionals.”

 

Date: 10/13/2021

1) Describe the day. Overall, what were some of your thoughts and feelings?

Today was super busy. I worked closely with the team to do follow up interviews, create treatment plans, modify medications, and act as a full member of the team.

2) Describe one interesting patient encounter. What did you learn?

I performed an interview with a young woman who was having continued psychosis for the past year. She had been hospitalized previously in another city and was diagnosed with MDD w/ psychotic features. She was on Seroquel 400mg HS and 50mg BID. She was readmitted to CP one month later with continued psychosis, bazar affect, and delusions. Her diagnosis was changed to schizoaffective d/o and was put on 10mg Zyprexa BID. She had been on this medication for 3 days and continues to have AVH. When I interviewed her she was unable to make eye contact, looking down and to the left w/o blinking. She was oriented and aware of medications and changes, her voice was soft, and slow rhythm. I thought that her symptoms presented more like schizophrenia with severe negative and positive symptomology. I suggested Clozaril as her psychotic symptoms were presenting as treatment resistant. Dr. Reddy agreed and we discussed starting her on this medication. This was my last patient of the day and he was going to start her on it the next day. I made sure to bring up the need to have her support system on board with this medication because of the intense regimen for blood draws and titration. I looked up several articles on how TR psychosis and long duration of first episode of psychosis is a poor prognosis and Clozaril is indicated for treatment.

3) Identify 2 clinical pearls you learned during the day.

1. In the inpatient setting, personality disorders are rarely addressed as a part of the treatment and will not be a diagnosis, only as a historical diagnosis. This is for two main reasons. The PD will not be the focus of treatment, but the symptoms while inpatient. The second is that often staff will treat a person’s PD with more dismissiveness than other DSM diagnoses.

- I understand the rational, I do not necessarily agree with it. Though, the groups provided within CP often address the needs a person with PDs (especially cluster B) and therefore are being treated.

2. Start by validating their feelings, don’t say “sorry” state what happened and their feelings from what they said get them in your corner, but do not stop there and then move on and transition to what is going to be done or else it reinforces their negative feelings, and they get left in their bad feelings.

               “use the however transition”

               Don’t simplify the challenge of emotions

Validate, transition, and let them do the work: baseline for good relationship

4) State one specific goal/objective that you will accomplish by the next log review (final).

I am still struggling with my Progress notes, they are not concise and sometimes not giving the information thoroughly, so long and rambling. I want to create a modifiable standard progress note. ** progress on this is ever evolving…

 

Date: 10/14-15/2021

1) Describe the day. Overall, what were some of your thoughts and feelings?

This post is a combination of two hours on Thursday night and then Friday day which is a combination of telehealth with a nursing home and inpatient geripsych. I spent time with patients on the Silver Linings side on my own today after Dr. Elkomy saw them. Most of them we just chit chatted about life, it was very nice. Sometimes it is nice to talk without an agenda.

2) Describe one interesting patient encounter. What did you learn?

I performed a SLUMS on a 77-year-old woman today. I watched several applications on YouTube prior to doing and did two in person with a nurse on the unit.

3) Identify 2 clinical pearls you learned during the day.

1. Seroquel used for sleep in the elderly can lead to urinary retention due to the predominantly H1 receptor antagonism at low doses, whereas at higher doses the dopamine and serotonin receptors are predominate.
2. Vistaril can cause urinary retention in the elderly.

4) State one specific goal/objective that you will accomplish by the next log review.

Psychopharm for sleep. This article I found was a great review of many different meds: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634348/

              

Date: 10/20/2021

1) Describe the day. Overall, what were some of your thoughts and feelings?

The hospital was buzzing with anxiety today. Three patients wanted to leave AMA, each were actively delusional and two required IM medications for threatening behaviors. This reminded me why I find inpatient so difficult for me personally. Especially if I am to make the calls as far as what medications to give, to restrain, to allow to leave…

2) Describe one interesting patient encounter. What did you learn?

Splitting. I spent some time with a patient who was staff splitting between myself and the PMHNP. “She was terrible, I was great, she doesn’t believe me, you are so nice…” While I felt like I helped calm her down and help her reason as to why we were not going to give her Ativan, I also know this was a continuation of the personality disorder.

3) Identify 2 clinical pearls you learned during the day.

1. Lithium is a better choice, than Lamictal, for bipolarities with patients who also have ETOH use d/o or chronic suicidality. Literature of efficacy is abundant.
2. Nuplazid/pimavanserin: medication for hallucinations in Parkinson’s. Not an antipsychotic.

4) State one specific goal/objective that you will accomplish by the next log review (mid or final).

https://www.psychiatrictimes.com/view/understanding-and-treating-co-occurring-bipolar-disorder-and-substance-use-disorders

• A number of different pharmacotherapies have been efficacious in treating co-occurring BD and SUDs. In early studies, lithium was found to improve BD symptoms and reduce levels of substance use.12 Valproate has also been found to be effective at improving affective symptoms, decreasing substance craving, and reducing alcohol and drug use.13,14 Compared with valproate, lithium is associated with lower suicide risk during treatment, but it may be less effective in treating bipolar illness associated with SUDs.15
• A number of studies have examined quetiapine in treating patients with co-occurring disorders. While quetiapine may reduce depressive symptoms, it did not reduce alcohol use.16 Findings indicate that lamotrigine and topiramate are not particularly useful in treating comorbid bipolar illness and SUDs.15,17 Thus, while the use of anticonvulsant mood stabilizers and second-generation antipsychotics for co-occurring bipolar disorder and SUDs is an attractive concept and may have some clinical utility, further research to substantiate these observations is warranted.
• In addition to mood-stabilizing agents, adjunctive addiction pharmacotherapies should also be considered in treating dual diagnosis patients. Naltrexone has been shown to significantly reduce both manic and depressive symptom severity and decrease alcohol use in patients with bipolar disorder and alcohol dependence.18