Midterm

Date: 08/26/21 (1 hour meeting) 08/31/21

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

Today was my first day with Stephanie Powell, PMHNP. Thursdays will be telehealth and a team meeting in the morning. The meeting is a time for providers to discuss their patients and possible avenues for treatment, questions, etc. After the team meeting we were unable to connect for patients in telehealth d/t technical difficulties

TODAY was my first day with Stephanie Powell, we met at the team meeting for ACT-TAY in the Jefferson City CHN Office. We

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

We worked with a young man who had been diagnosed with schizophrenia four years ago. He was well dressed, oriented to four spheres, polite and calm. Yet after about 3 minutes we started to recognize that his speech was disorganized and had been experiencing visual hallucinations and having delusional thoughts that have been persistent despite being adherent to q 3-week Invega injections. The provider had seen him 4 weeks ago for the first time (she “inherited” a group of clients) via telehealth. She had not noticed his thought content at the time and she had not asked about hallucinations, yet he stated today that he experiences them regularly for the past 6 months. She decided to add on lithium since he was also experiencing some apathy and depressive mood. What I learned was that some things can get lost in telehealth and therefore it is extra important to ask about specific symptoms.

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

• Per Stephanie: Lithium can be an effective adjunctive therapy for persistent hallucinations and mood symptoms in patients with schizophrenia being treated with an antipsychotic.
• ACT-Tay: I am learning about the goals, purpose, and process of how CHN is implementing ACT-TAY (transitional youth 16-26 yrs) Assertive!

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

Research augmentation of LLA w/ lithium for continued hallucinations and depressed mood, I would like to see the effectiveness of this combination.

I am having trouble finding research on my question: Lithium as adjunctive with antipsychotic for schizophrenia. I will continue to look into this. Initial thoughts on this intervention: review of patient’s bp and kidney function, he is a young AA male who may have a predisposition to pervasive HTN that can cause renal impairment; I also thought he needed a UDS/questions on substance use to help rule out substance induced symptomology.

 

Date: 09/02/2021

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

               I got to spend quite a bit of time with a social worker and RN involved the ACT-TAY program

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

It was hard to have a meaningful or interesting patient encounter because of how few patients we saw. But one thing that stood out to me was I sat in on the RN to patient pre-session encounter and there was a better rapport and overall openness between them than between the PMHNP and patient. I am sure this is due to several reasons. But it also reminded me that when I was an intake nurse for MUPC that I really had to intentionally not overstep my questioning to make sure the patient still had the energy left to discuss what was happening to them. I found while working there that the catharsis that can happen with the first interview can lead to the patient not being as open or honest with the provider. Though this is outpatient and not inpatient.

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

• Abilify can be augmented with Prozac to increase the half-life due to drug/drug elimination affects, “Aripiprazole, an atypical antipsychotic, which is a partial agonist at the 5-HT1A receptors, is equally metabolized viaboth CYP3A4 and CYP2D6 isoenzymes Therefore, coadministration with fluoxetine (a potent inhibitor of CYP450 2D6) may significantly increase the plasma concentrations of aripiprazole. On the other hand, aripiprazole has no known effect on fluoxetine metabolism (Kim et al., 2021)
• I participated in a COVID q/a for Compass Health Network. There were several employees who were quite angry with the company, stating: “quit shoving this down our throat.” The physician moderator was very patient, stuck to the topic and answered questions without taking the argument bait or going the other way of pacifying the person. I paid close attention to how he facilitated this because examples of professionalism like this are always pearls for me. I tend to placate people when it is a professional relationship.

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

Create a table comparing the different Neurocognitive Disorders, include findings, presentations, and interventions. 09/4/21 this was completed!

 

Date:  09/07/2021

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

Today was my first day at Royal Oaks in Windsor, MO. I am working with Tonya Tyler. Today I learned a lot about her role as an inpatient provider and how she works with the different providers. I am looking forward to seeing more patients tomorrow. Tonya is very proactive in letting me be a part of the process. Having a limited amount of time together, we are jumping right in.

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

We did an initial evaluation on a 17-year-old female who came in voluntarily for SI and worsening depression. The provider created a great rapport while getting a thorough evaluation and providing education.

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

1. During the covid epidemic many more children have been coming in for ADHD. This may be an adjustment disorder.
2. Abilify is great for adjunctive/mixed dep/bipolar, not great for schizophrenia. This pearl was given by my preceptor, and I think it is her experience and probably the same thoughts of the providers she works with. I looked up and found a recent meta-analysis (Kim et al., 2021). I want this medication to be effective for schizophrenia because of the improved side effect profile in some aspects. The following states how it is in aspects more favorable/effective and in others it is not. This is where provider preference and experience comes into effect.

 

“Specifically, aripiprazole was more favorable than paliperidone for triglyceride levels and more favorable than risperidone and olanzapine, but less favorable than ziprasidone, for weight gain. In addition, aripiprazole was less favorable for akathisia compared with second-generation D2R antagonists, in particular olanzapine and quetiapine, and less favorable for discontinuation due to inefficacy than risperidone. Lastly, aripiprazole was more favorable than haloperidol for various efficacy and tolerability outcomes. In conclusion, aripiprazole’s efficacy did not differ substantially from D2R antagonists in the early course of schizophrenia, whereas differential tolerability profiles were noted. More double-blind RCTs are required comparing the efficacy and tolerability of aripiprazole as well as other D2R partial agonists with D2R antagonists in early stages of schizophrenia.” (Kim et al., 2021)

 

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

The provider I work with said that she really like Thorazine for children and I always thought that it is better for PRN in children or in severe cases due to the side effect profile. Commit to memory: Chlorpromazine administration, titration, monitoring in children and adults

              

	FDA/Off-Label	Dose PO/IM Psychiatric use only	Monitoring
Children	·        Severe behavioral problems w/ ODD, other disruptive behavioral disorder, ADHD w/ excessive motor activity w/ accompanying conduct disorders. ·        I/M for acute agitation in hospital.	·        Oral: 0.55 mg/kg q 4-6 hours; increase as need to control symptoms, titrated for at least 2 wks ·        IM: 0.55 mg/kg every 6-8 hours as needed.	·        ANC wkly for 6 months → q 2weks for 6mths → q mnth after that ·        Do not start if initial ANC is <1500 ·        Guidelines are complex if ANC drops < 1500 during treatment ·        Fasting glucose/lipids ·        Serum level monitoring usually shows therapeutic response at 350-450 ng/mL; increased risk of toxicity if >700ng/mL.
Adolescents	·        Same a child plus: other non-psychiatric indications.	Same as child
Adults	·        Schizophrenia ·        Acute psychosis (IM) ·        Same as pediatric population	·        Oral: 12.5 mg daily or BID, gradually increase in 25-50mg increments; Target dose 300-450mg/day after two weeks (some as high as 600-900mg/day) usually divided **If interrupted >48 hours, must restart titration ·        IM: 25-50mg q 3-4 hours

 

              

Date: 09/08/2021

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

It was a very full day today. I did full assessment on two new patients with a marked improvement from the first interview to the second. Reflections I had on this outside of pure nerves being the first interview that Tonya watched. He was 6’8” and med history showed the potential for behavioral outbursts, multiple hospitalizations, and report that he had needed IM Ativan. But upon meeting him he presented meek and scared. He even said that he felt scared. I think my prejudgment influenced how I started with him which in turn influenced the interview.

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

The last patient we did an intake on was quite a conundrum and I think she may be the case that I present in December. She was admitted for suicidal ideation with the following diagnoses: ADHD, ODD, Bipolar. She has a 9-month history of cutting. Ultimately, she is being diagnosed with conduct disorder with childhood onset.  But is was amazing how she told explicit lies and the explicit truth throughout her interview. Denying multiple facts that were later verified, and in the next sentence telling the full truth. She had little to no facial expression and showed little remorse for her actions.

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

1. Olanzapine is recognized as off label in Stahl for BPD. I want to find what exactly it is indicated for in BPD, impulsivity?
2. Multisystemic therapy (MST) targets family, school, individual, with a focus on improving family dynamics, academic functioning, and improving the child’s behavior in the context of multiple systems.

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

               Conduct disorder: Prevalence, risk factors, interventions. I will look this up tomorrow.

• General population: Boys range from 6% to 16%; girls range from 2% to 9%
• Findings support the importance of early interventions targeting parenting behaviors to reduce risk for the development of antisocial behavior, and inform developmental models of antisocial behavior in adolescence through adulthood
• Antidepressants such as fluoxetine (a selective seratonin reuptake inhibitor, or SSRI) may benefit patients with depressive, rigid or inflexible aggressive behaviors. Restlessness, behavioral activation and suicidal ideation should be monitored, particularly early in the treatment, and parents need to be notified of side effects. If ADHD is a comorbidity, some physicians prefer bupropion to an SSRI.
• Anticonvulsants including lithium have been used to treat aggression and mood lability symptoms associated with bipolar disorder. Because monitoring side effects and blood levels is important, a family’s ability to comply with treatment and follow-up should be considered.
• Beta-blockers such as clonidine have been used to control impulsivity and aggression. Vital signs, dizziness, sedation and potential tolerance or dose changes should be monitored.
• Atypical antipsychotics such as risperidone are used to treat aggression. These medications are also used to treat mood lability and bipolar symptoms. Weight gain and risk for metabolic disorder should be followed closely
• Approximately one-third of children with conduct disorder go on to develop antisocial personality disorder

 

Date: 09/09/2021

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

              

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

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

1. Concerta vs amphetamine salts: Salts enter the cell leading to shorter more “intense” pharmacokinetic action and pharmacodynamic response. whereas Concerta acts in the synaptic cleft causing more gradual changes, versus the quick up and down. Dr. Arian will change current stimulant to Concerta, endorsing its increase in efficacy.
2. “Both MPH and AMP inhibit the reuptake of DA and NE from the synapse into the presynaptic neuron by blocking their respective monoamine transporters (i.e. DA transporters [DAT] and NE transporters [NET]) [9,17]. In contrast to MPH, AMP is also thought to induce an increased release of these monoamines from presynaptic terminals by: 1) blocking vesicular monoamine transporter 2 (VMAT-2), which in turn increases cytosolic levels of monoamines; 2) reversing the transport of cytosolic monoamines into the synapse via DAT and NET; and 3) preventing the breakdown of cytosolic monoamines by inhibiting monoamine oxidase (MAO) activity” (Childress et al., 2019) This states how the first pearl in true more thoroughly. But it is also important to take into account the stimulants that are long acting by prodrug metabolism.

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

Better understand how nurse practitioners are providing psychopharmacological help for children with ADHD in Missouri. I am going to talk to Stephanie Powell about this. This will help me with the CPA project as well.

 

Date: 09/10/2021

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

Last day at RO. This was the most interesting day by far, I am starting to get back into the groove of things. Tonya has been hard on me and it has been great! She calls it like it is and is open with both criticism and praise. When I have such little time to be here with her, and before graduation, it is really nice to get down to the nitty gritty and not fool around.

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

So far today I have been working on a case (will see him soon) of a young man who has self-harm and continued/repetitive thoughts of mass shooting at school, tells others that he has raped girls and then has been noted to follow girls home.

 

Interview with this adolescent boy went well. Goal was to see him in 50 min, I took 70 (work in progress). This was very an interesting interview. I will do a full write up on him for my records. His diagnosis was DMDD and PTSD. I would have also given him ocd or at least a provisional diagnosis of ocd which I think may be contributing to his intrusive violent and obsessive thoughts. I also think he would benefit from Autism testing. He has psychotic features that are not being addressed in the diagnosis though I am seeing article on psychosis accompanying PTSD, but this is not recognized in the DSM. Psychiatric Times: “Auditory hallucinations feature prominently in many psychiatric disorders. It has been estimated that approximately 75% of people with schizophrenia experience auditory hallucinations. These hallucinations are also relatively common in bipolar disorder (20% to 50%), in major depression with psychotic features (10%), and in posttraumatic stress disorder (40%).” Per report he is hearing clear voices, male and female, outside of his head that repeat phrases to harm himself. While I will ask you (DR. ELLINGTON) about this. I thought he may have schizoaffective disorder, reporting periods of time of increased energy, goal directed behavior, but also reporting an almost constant ambivalence to his own worth and life. I was not getting a DMDD feeling except for the constant irritability. He is being started on Risperidone, 0.25 BID, which was the same medication that I was going to start him on. I did not want to initiate a ssri, with the fear of activating him and having him act on his psychotic/command hallucinations.

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

1. This isn’t exactly a pearl that I learned from outside someone else but one I am picking up on now that I have been in several clinical settings and with several providers. Providers seem to fall into diagnostic ruts. There is a tendency to steer into certain diagnosis and many providers lack knowledge of a wide array of diagnosis. And while I fall into this category of inadequate proficiency, I continue to do a long DD list to help me look into possibilities, I reek of student! Dr. Quadri homed in on the need to be very familiar with the whole DSM. While it is not appropriate to call a horse a zebra it is equally important to know the characteristics of a zebra when you come across one.
2. OCD is most commonly treated with SSRIs, and at much higher doses than used to treat anxiety or depression

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

I am going to reread the DSM5 OCD section and make flash cards of the information.  This will be done this weekend.  Done.

 

 

Date: 09/14/2021

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

Today we went to 5 homes for medication management and follow up. It was myself, Stephanie Powell, and the RN. This is a component of the ACT-Tay. What a great experience to go into the community. Seeing patients in their home environment is enlightening.

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

We visited a young man who we had started on Lithium two weeks ago who presented with disorganization and anhedonia. Today his thoughts were linear though his affect was more apathetic. His insight was improved, and we were able to perform a more thorough education that I had thought lacking on the previous visit. His dose of Lithium low and we are waiting for his blood lithium level, so Stephanie is aware that some of the improvement may be due to extraneous factors such as decreased marijuana use and placebo, but subjectively he did appear better in his MSE.

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

1. Starting Bupropion at 75mg can help to get a patient tolerated, mitigating irritability that can accompany Bupropion then increase the dose to 150. Some patients will still have irritability at 75mg, irritability is a common reason people discontinue the medication.
2. Refractory depression after methamphetamine use is difficult to treat. Bupropion has been noted by provider to be effective over many other treatments with both depression and sustaining abstinence, not necessarily taking away craving but use.

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

Make flashcards of the dopamine pathways and how different disease states and medications affect them. This will be done tomorrow.  (done)

 

Date: 09/16-17/2021

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

The 16^th was a total bust, a bunch of no-shows, with a couple who did not want to have a student. I was told that this is the difficulty with ACT-TAY and the beauty. These transitional youth need the ASSERTIVE component more than other clients. Stephanie said I could join her for a few hours on the 17^th. This is her day that is adult patients, and she sees them back-to-back. She has been hesitant to have me there due to the fast pace and how she often feels overwhelmed by it. I think as we are getting to know each other more, she is feeling more comfortable having me around.

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

One of the great aspects of having multiple preceptors is being able to see what how I may do something different than them. For example, we worked with a 33-year-old man today who was experiencing 5/10 depression. He was flat, complained of lack of energy and anhedonia. He is unemployed, lives alone, and appeared very depressed. The provider increased his Zoloft from 100 to 150, she scheduled the follow up for 3 months. If it were me, I would have had a follow up in 2 weeks to 1 month to evaluate his symptoms. He denied suicidal or harm thoughts, but if his depression did not take a turn for the better soon, I would be concerned that 3 months would be too long of a time frame.

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

1. I found an interesting article on Baclofen for the treatment of AUD and dependance in patient with cirrhosis. I was looking for what the best medications were for people to reduce craving/use with AUD and cirrhosis. Stephanie said Acamprosate can be given, since not metabolized in liver but it can still have serious side effects. (Addolorato et al., 2013). I know someone who has used Baclofen for AUD and it worked. (This is what has sparked my interest in off label prescribing scholarly inquiry)
2. “Baclofen, a GABA-B receptor agonist, is a promising treatment for alcohol use disorder (AUD). Its mechanism of action in this condition is unknown. GABA-B receptors interact with many biological systems potentially involved in AUD, including transduction pathways and neurotransmitter systems. Preclinical studies have shown that GABA-B receptors are involved in memory storage and retrieval, reward, motivation, mood and anxiety; neuroimaging studies in humans show that baclofen produces region-specific alterations in cerebral activity; GABA-B receptor activation may have neuroprotective effects; baclofen also has anti-inflammatory properties that may be of interest in the context of addiction. However, none of these biological effects fully explain the mechanism of action of baclofen in AUD. Data from clinical studies have provided a certain number of elements which may be useful for the comprehension of its mechanism of action: baclofen typically induces a state of indifference toward alcohol; the effective dose of baclofen in AUD is extremely variable from one patient to another; higher treatment doses correlate with the severity of the addiction; many of the side effects of baclofen resemble those of alcohol, raising the possibility that baclofen acts as a substitution drug; usually, however, there is no tolerance to the effects of baclofen during long-term AUD treatment. In the present article, the biological effects of baclofen are reviewed in the light of its clinical effects in AUD, assuming that, in many instances, clinical effects can be reliable indicators of underlying biological processes. In conclusion, it is proposed that baclofen may suppress the Pavlovian association between cues and rewards through an action in a critical part of the dopaminergic network (the amygdala), thereby normalizing the functional connectivity in the reward network. It is also proposed that this action of baclofen is made possible by the fact that baclofen and alcohol act on similar brain systems in certain regions of the brain.” (de Beaurepaire, 2018).

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

How off label can a PMHNP go. For example, the person I know who used baclofen, it was prescribed by his PCP for AUD (cravings). It took two very strong/concerted tries, and the second one was piggie backed on a medical condition and concurrent psychopharmacology for anxiety/depression/ADHD. Baclofen works on GABA in the spinal cord and is FDA approved to treat: reversible spasticity associated with multiple sclerosis or spinal cord lesions. It is also used to treat chronic neuropathic pain. I will ask some providers and get their input on this.

 

Date: 09/27/2021 (Dr. Reddy)

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

This experience is exactly what I need right to balance out my clinical experiences. Dr. Reddy let me do follow ups on 4 patients. This included the interview, plan with medications, and write up. I then presented to him. We discussed the medication plans etc. He either said yes, I agree, no, this is why, or let’s wait, and this is why. I then followed his nurse practitioner for two intakes that were very interesting. She does a nice job.

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

Interview with 38-year-old Caucasian woman. She came after thinking about overdosing. She is clearly delusional and experiencing auditory hallucinations, has a history of depression, schizophrenia, and bipolar. We discussed a diagnosis of schizoaffective disorder, which is her provisional diagnosis. Her MS was a perfect example of circumstantial thought process. She also appeared to be thought blocking and experiencing internal stimuli, yet denied when asked about current AVH. She had a buprenorphine patch on. She was willing to take it off but and will be started on withdrawal protocol, may start on Suboxone if she is willing.

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

1. More complicated comorbidities that include depressive symptoms may require higher doses of an antidepressant. Zoloft can be a good choice because of its wide therapeutic range.
2. Librium is a good benzodiazepine option to give preventively to patients in alcohol withdrawal who have a history of complicated withdrawal.

• Chlordiazepoxide 24-48 hr elimination half-life
• 50 to 100 mg orally, followed by repeated doses as needed until agitation is controlled-Maximum dose: 300 mg orally per day. This is much higher than the dose for anxiety, even severe anxiety and was found online (drugs.com), no information in Stahl for withdrawal dosing.
• Parenteral formulations are usually used for the relief of withdrawal symptoms of acute alcoholism.
• After agitation is controlled, the dosage should be reduced to maintenance levels.
• UpToDate: Patients with a history of seizures, delirium tremens (DT), or prolonged, heavy alcohol consumption, who are minimally symptomatic or asymptomatic and are admitted to the hospital for other reasons, can be prophylactically treated with oral chlordiazepoxide, or with oxazepam if severe liver disease is present. Should more severe symptoms develop, patients are treated for active withdrawal in standard fashion. (See 'Management' above.) For prophylaxis, we give chlordiazepoxide 25 to 100 mg every six hours for one day, followed by 25 to 50 mg every six hours for an additional two days. A similar regimen can be used with oxazepam 10 to 30 mg. Monitoring is no different from patients in active withdrawal. Patients should be reassessed frequently and additional doses of medication given each hour if a score of 8 or greater is achieved on the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). If such scores are reached, prophylaxis has failed and patients should be treated for active withdrawal (table 4) [48].

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

Does suboxone help with pain. If buprenorphine is used for severe pain does the addition of naltrexone effect the pain relief properties? I will look this up now.

“The current data suggest that bup/nal can be used as an effective outpatient office-based treatment for opioid addiction. It can also be used, as an alternative to methadone, in opioid replacement therapy to help opioid dependent patients reduce opioid use. Bup/nal, as a weak analgesic, appears to be not as effective in non-opioid dependent chronic pain patients. However, it has been successfully used for pain relief in opioid dependent chronic pain patients possibly due to the reversal of OIH. Future studies should address the implications of bup/nal therapy in clinical anesthesia and perioperative pain management.” (Chen et al., 2014)

• Suggesting that suboxone may help with the dependence and less severe chronic pain in some patients but will be less effective in pain management than buprenorphine. Definition of OIH: “Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.”

              

 

Date: 09/30/2021

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

Today was split between doing telehealth with Stephanie Powell and my first day with Dr. Elkomy. Thoughts and feelings: While I really appreciate ACT-TAY, and I think the foundation of it is a great model, I find it kind of tedious. Many of the members do not want the interventions and are not necessarily there by choice, it leads to many no-shows and what feels like fruitless interventions. But we saw one woman today with such an awesome story of coming together and making the most out of the help that has been provided. There are so many expectations in the “helping” fields of work and I am continuously learning to examine my motivations. Not that I think I am in the wrong line, but I get concerned that I am motivated by doing good for my sake over the sake of the patient. I am listening to some lectures in the Barkley review and I was struck by the statement the lecturer gave about the failure is not on the patient but on the therapist and the therapy. In programs like ACT-TAY, I think there is a fundamental idea that this is best practice and therefore modifications on interactions don’t need to be made. I don’t think this is making much sense, but something to think about for me. As far as my time with Dr. Elkomy. I like her and I think I will learn a lot. See pearl today on a topic we discussed at length.

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

We spoke with a 90-year-old woman. She was beautiful and kind and funny. I remembered how much I like to work with geriatric patients, especially when they are able to talk.

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

1. Lamictal can be very effective in treating an adolescent patient when you suspect a bipolar (2) but they still have insufficient symptoms to be diagnosed with it. I found an article that discussed “mixed depression” which Stahl describes as on the spectrum from depressed to manic, between depression and bipolar 2.

“Currently, AD monotherapy should be avoided in patients strongly suspected as having bipolar depression or MDDs with mixed features. In these patients, a combination or adjunctive treatment with MSs or AAPs is recommended when it is considered beneficial to use ADs. MS efficacy studies on bipolar depression suggest that lamotrigine is the most reliable; lithium is expected to have modest effects, and evidence is still lacking regarding the efficacy of valproate and carbamazepine. To prevent long-term episodic relapse in BDs, MSs may also be recommended, either alone or in combination with other MSs and AAPs.” (Shim et al., 2017)

2. Treatment for neurocognitive behaviors: Treatment for behaviors associated with neurocognitive disorders must be a balance of being able to improve the behaviors enough that the patient will no longer be rejected by their family, care givers, society while also being a reasonable/safe intervention. Reaching full remission is not necessarily in the picture but restoring the ability for them to be able to be around others and not ostracize themselves. For Example, Dr. Elkomy discussed that many children of patients (who are their guardian) will refuse the use of antipsychotics because of the side effect profile while also saying they can no longer be around their parent because of: disrobing in public, aggression, outbursts of anger etc. So, while there may be some danger associated with them, if they are completely rejected by their people, what is the point of living? She discussed how she gets fearful calls from the pharmacist saying: you CANNOT HAVE THEM ON THESE TWO MEDS. When (in her experience) if these medications are given the risk mitigated by low dosing, slow titration, and monitoring. But gives them some of their life back and while long term it may cause some worsening of symptoms, they are so- bad now that they have no quality of life. I know this was not very eloquently put, but I wanted to put it down so I can continue to think about it.

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

Memorize the Erikson Stages by next Friday. I know we are supposed to have them already memorized, but, I don’t. I will write them here by memory… 😊

 

Infancy	0-18 months	Trust vs Mistrust	Feeding		Success: Children develop trust when caregivers are reliable/care/affection Failure: mistrust
Childhood	2-3	Autonomy vs Shame/Doubt	Toilet Training	Develop a sense of personal control over physical skills/ independence	Success: Personal control/independence  Failure: Shame and doubt in self/abilities
Preschool	3-5	Initiative vs Guilt	Exploration	Begin asserting control and power over environment	Success: sense of purpose Failure: Disapproval leading to guilt
School age	6-11	Industry vs Inferiority	School	Cope with new social and academic demands	Success: Sense of competence Failure: feelings of inferiority
Adolescence	12-18	Identity vs Role confusion	Social relationships	Develop a sense of self and personal identity	Success: Ability to stay true to self Failure: Role confusion/weak sense of self
Young Adult	19-40	Intimacy vs Isolation	Relationships	Need to form intimate, loving relationships w/ others	Success: Strong relationships Failure: Loneliness/isolation
Middle Adult	40-65	Generativity vs stagnation	Work/ Parenthood	Adults need to create and nurture things that will outlast them	Success: Creating positive change → feelings of usefulness Failure: Shallow involvement in society
Maturity	65+	Ego Integrity vs Despair	Reflection on Life	Look back on life	Success: Feelings of wisdom Failure: Bitterness Dispair

 

 

 

Date: 10/1/2021

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

Today was fine, we went to a nursing home as well as worked at CenterPoint reassessing patients from last night. The nursing home was interesting and not conducive for great psychiatric care. We had 40 patients to review, I could not stay as long because I had to pick up my children but of the patients I did see, it was almost impossible to get good information or to make changes to medications. Not a great system.

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

We did a SLUMS on a patient today. Her score was 7. It was such a surprise for us as the way she holds herself and communicates I never would have expected it to be so low. But she really struggled. This was the first time I have done one of these screenings and I found it helpful to do with someone else.

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

1. When doing cognitive screening, it is OK to add 5 points if it seems that they have increased anxiety that is impairing their ability to pay attention, though I could not find any literature that correlates this. Though I did find an article that states most of the cognitive screenings are fairly consistent between times when a person is more or less anxious therefore adding to improve the score may not be necessary. Though with a score of 7, it made no differences. Additionally, this is a screening for further investigation, not a diagnostic tool.
2. Flu and covid vaccinations are recommended to be given either at the same time of 6 weeks apart.

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

Figure out a way to best utilize Dr. Elkomy. Her expectation seems to be for me to observe and then ask questions, but so far I am having a little difficulty finding good questions to ask because the interactions are so short. She is very open to talking so I am going to do a little research on how to engage with smart questioning with a preceptor. I think I am going to focus on prioritization in the geriatric population and collaboration with the physician.

                

 

Date: 10/05/2021

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

The day started with the team meeting and then we saw patients. Again, we had several no-shows. I did the initial interview on a patient and Stephanie reminded me that I need to be able to go faster and keep track of time. She communicated this in a very supportive way, with the intention to help me in my future practice and not spend many hours over charting and catching up. It is so hard though, especially when patients are difficult to reign in due to their disease process/substance use/personality. Additionally, I am a talker…

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

I interviewed a young man today who had smoked marijuana before coming in. He told me that he uses marijuana every day and that it the only thing that helps him with his anger and anxiety. I was doing the interview on my own so I am not sure if he had been my patient, I would have continued the interview. Though, he had rescheduled multiple times and I thought it was important he was there for treatment. He was extremely circumstantial in the beginning, which could have been due to the intoxication or anxiety.

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

1. Second generations can lower the seizure thresholds. We saw a patient today that I was thinking about Olanzapine, but he has a history of seizure-like activity (non-confirmed). We started him on Depakote. The cool think about this medication for him is he has daily HA, seizure like activity, and irritability/aggression and Depakote may help with all these symptoms.
2. Our patient discussed his daily morning upset stomach and vomiting. Stephanie told me about: cannabis hyper emesis syndrome CHS which is induced by chronic cannabis use and they suffer from repeated bouts of vomiting. In between these episodes are times without any symptoms. Healthcare providers often divide these symptoms into 3 stages: the prodromal phase, the hyperemetic phase, and the recovery phase.

Prodromal phase. During this phase, the main symptoms are often early morning nausea and belly (abdominal) pain. Some people also develop a fear of vomiting. Most people keep normal eating patterns during this time. Some people use more marijuana because they think it will help stop the nausea. This phase may last for months or years.

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

Mood stabilizers: best for types of symptoms (treat from bottom/treat from top) This will be done by the final.

• Lithium
• Lamotrigine
• Depakote
• Carbamazepine
• Oxcarbazepine

Date:  10/06/2021

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

I am very glad that I was able to get the clinical hours at CenterPoint. I am actually working with patients on my own and coming up with treatment plans, albeit less comprehensive than the provider, but slowly working my way there. I have the opportunity to work with a PMHNP and Dr. Reddy, both of whom are very open and trusting.

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

I spoke with a woman at length today who has an alcohol use disorder, with fairly good insight but still not committed to not drinking. I facilitated in an MI way her exploration of the connection between alcohol and outcomes she does not want in her life (fighting with fiancé, being angry/short with daughter, forgetting periods of time, and feeling unable to control her drinking, and ultimately her depression). There was no judgement and no pushing but helping her come to the conclusions on her own. Yet she was still not ready to make a full commitment. For me, the process of facilitation verses leading really helped me not have the need to convince her of anything, which has always been a issue moving from a person who likes to help people get better to a professional position.

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

1. Having a competent and experienced provider to collaborate with is essential when working inpatient. The number of psychotropics that some of the patients are on are numerous and then even more challenging when they have tried and failed numerous other drugs. This isn’t a real exciting pearl but as I start to think about my next moves (inpatient, outpatient, or whatever I can get…) Starting to feel nervous about finding a job, especially since moving is not in my future.
2. Formulary medications and medications that will be paid for by insurance is a big component of medication adherence. Yet, it seems that it doesn’t always follow best practice, this is a real shame!

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

Read about Medicaid and Medicare acts. I am still pretty ignorant on details, and I know it will be tested on.

 

Date: 10/07/2021

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

I like to work and be busy. Sitting around waiting for clients to come or not come is a little frustrating. I think that is why I have liked being at the hospital, no no-shows. I know this is more common in certain populations, like ACT-TAY who see like three different providers a week, but it is challenging. I guess it would be nice as an opportunity to catch up on charts etc, but it seems to have a feast of famine

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

Worked with a young man who has bipolar 2 and coming down from a hypomanic phase. He wants to treat his bipolar with

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

1. Working with a patient who either wants a medication to fix everything or only therapy when therapy and medication is the best practice using the following can help from both ends: either Therapy and putting the work is very effective and can help with “80%” of the symptoms but medication can help make the therapy more effective and give the extra that is needed to really impact the symptoms. OR Medication will only be effective with part of the symptoms but putting the work with therapy is much more effective and lasting to help with symptom relief.
2. Use of Provera for patients w/ dementia who are sexually acting out. (Light & Holroyd, 2006)

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

               I will perform a SLUMs independently.