NO CURES AVAILABLE 3/5/2022 Requested Dr.P to discuss history with Dr. Jakkula before appointment. Deepa 03/01/2022


As telehealth/video provider, I Jagan Jakkula MD, attest that I introduced myself to patient, provide the credentials, disclosed my location , other participants in the virtual visit , and the reason for real time two way interactive audio and video consult , I and patient have mutually agreed that this visit is appropriate for video technology .

Originating site (Patient location) : patients home
Distant location(provider location) : Irvine, California

Patient seen for follow up for medication management . accompanied by mom. says he is doing better, says taking lamictal ,just started higher dose- says tolerating it , says seems to help to some extent . says still feeling down, anxious somedays . denies panic attacks .. gets 6-7 hrs sleep/night . noted to be delusional -seems to be chronic in nature . says he has bipolar -unable to give a clear hx for manic/hypomanic symptoms . denies command , visual, auditory hallucinations , suicidal thoughts , self injurious behaviors , homicidal thoughts .. reports compliance with medications, tolerating except as above

substance abuse hx: per chart review- unable get from pt at this time


SUBSTANCE ASSESSMENT HX:
-cannabis: Endorsed
last used last month
-alcohol: denied
-meth/cocaine: endorsed
onset: age 20
amount: < 1 gm/month
last used: a month ago
-Nicotine use/Vaping: never smoke, per patient

Review of systems :
Constitutional: negative
Endocrinology: negative
Skin: negative
Respiratory: negative
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal: negative
Neurological: negative
psychiatry : see HPI

Lamictal, take 2 tablets twice a day (Edited by JAGAN JAKKULA on Mar 24, 2022)

The patient's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen :better , anxious, irritable -mood congruent .. Thought processes -tengential, disoragnised . dneies suicidal/homicidal thoughts . The patient's judgement -seems impaired . Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events

Schizoaffective bipolar by hx

pt and mom reports improvement in mood/psychotic symptoms but not optimally controlled . d/w consider alternate medications , optimize medication dose -agreeable with plan
will get medical records for review

Increase lamictal to 50 mg bid after 2 weeks . psychoeducation provided about diagnosis ,treatment plan, interactions with other medications . medication side effects, risks, benefits and alternatives was discussed including periodic monitoring of parameters
individual therapy recommended
if worsening symptoms , call my office
obtain medical records from previous provider
safety plan:
patient agrees to utilize the following resources in the event of
acute suicidal urges: ER,walk in clinic, crisis line/team, stay with family, structured plans, call contact person
short term goal: obtain all medical records, medication tolerance
long term plan: remission of symptoms and maintain stability
patient understands and agrees with plan
f/u in 3-4 weeks or sooner if needed

Requested Dr.P to discuss history with Dr. Jakkula before appointment. Deepa 03/01/2022


As telehealth/video provider, I Jagan Jakkula MD, attest that I introduced myself to patient, provide the credentials, disclosed my location , other participants in the virtual visit , and the reason for real time two way interactive audio and video consult , I and patient have mutually agreed that this visit is appropriate for video technology .

Originating site (Patient location) : patients home
Distant location(provider location) : Irvine, California

Patient seen for initial evaluation , referred for medication management . per chart review- patient currently on lamictal, cariprazine-says he is not taking them , says he is waiting to see this provider before start taking -says cariprazine is expensive , cannot afford , wants to try alternate medications . says he has seen dr frooqi in the past, seen np recently . accompanied by mom. says currently living with mom . says he needs to get back on his medication . says he wants this provider to acknowledge "gang stalking" and wants the provider to read up on "gang stalking" and attest that the disorder called "gang stalking" is real . says he has been off his medications for last year . says diagnosed with schizoaffective - bipolar . says he moved to california since 2017 , says he was diagnosed with bipolar about 15 years ago. says he was admitted to in pt psych unit few times-says thinks he was manic at that time . denies hallucinations .says sleeping ok. says he is very anxious , says he is unable to get care for his medication . says he is feeling depressed and anxious . patient endorses low mood, anhedonia ,low energy ,motivation, hopelessness, , low psychomotor activity, constant racing thoughts , unable to relax, fidgety . denies panic attacks . says he is sleeping well . gets 7-8 hrs sleep/night . noted to be delusional -seems to be chronic in nature . says he has bipolar -unable to give a clear hx for manic/hypomanic symptoms -says bipolar gets worse when off medications . denies ptsd symptoms including nightmares, flashbacks, avoidance . denies command , visual, auditory hallucinations , suicidal thoughts , self injurious behaviors , homicidal thoughts . denies OCD symptoms . denies childhood hx of ADHD. reports currently off psychotorpics .

substance abuse hx: per chart review- unable get from pt at this time


SUBSTANCE ASSESSMENT HX:
-cannabis: Endorsed
last used last month
-alcohol: denied
-meth/cocaine: endorsed
onset: age 20
amount: < 1 gm/month
last used: a month ago
-Nicotine use/Vaping: never smoke, per patient

Review of systems :
Constitutional: negative
Endocrinology: negative
Skin: negative
Respiratory: negative
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal: negative
Neurological: negative
psychiatry : see HPI

Reported multiple inpatient psychiatric holds/hospitalizations: Pennsylvania, in 2017, on his way to Washington DC, to discuss the topic of "Gang stalking" with authorities; San Bernardino Comm. Hosp. in 2020; January/2021 - 2 weeks at Arrowhead BMC, Colton, CA; and October/2021 at Canyon Creek Beh. Health, Texas, for 2 weeks.






RISK ASSESSMENT:

-Suicidal thoughts: patient denied

-History Suicidal Plan/Attempts: patient denied

-Homicidal Ideation: patient denied

-History of Harm to Others: patient denied

-Access to firearms or other weapon(s): mother endorsed, but locked

Hyperlipidemia
Type II DM
HIV POSITIVE

denies past surgical history

denies

PsychSHx

-Marital Status/Kids: single with no kids

-Living Situation: living with mom, since 2017

-History of Abuse/Traumas: denied

-Employment/School /Occupational Status: on disability benefits

-Highest Education: 12th grade

-Current or Prior Military Service: denied

-Support/Social Systems/Network: mother and friend (Luis)

-Legal/Forensics Hx: jailed once in Texas

-Religion/Spiritual Belief: Christian

-Sexual Preference: identifies as gay

-Use of Herbal/Nutritional Supplements: denied

Lamictal, take 1 tablet daily for 2 weeks, then 1 tablet twice a day (Edited by JAGAN JAKKULA on Mar 7, 2022)

The patient's speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen : anxious, irritable ,sad -mood congruent .. Thought processes -tengential, disoragnised . dneies suicidal/homicidal thoughts . The patient's judgement -seems impaired . Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.

Schizoaffective bipolar by hx

pt and mom reports mood/psychotic symptoms not optimally controlled -off psychotorpics - contributing factors as above. d/w consider alternate medications , optimize medication dose -agreeable with plan
will get medical records for review from dr farooqi .

start lamictal 25 mg daily for 2 weeks, then 25 mg bid . psychoeducation provided about diagnosis ,treatment plan, interactions with other medications . medication side effects, risks, benefits and alternatives was discussed including periodic monitoring of parameters
individual therapy recommended
if worsening symptoms , call my office
obtain medical records from previous provider
safety plan:
patient agrees to utilize the following resources in the event of
acute suicidal urges: ER,walk in clinic, crisis line/team, stay with family, structured plans, call contact person
short term goal: obtain all medical records, medication tolerance
long term plan: remission of symptoms and maintain stability
patient understands and agrees with plan
f/u in 3-4 weeks or sooner if needed

"I am a targeted individual for 16 years by number of individuals, "

A 56y/o, Caucasian, male, seen for initial evaluation, in company of mother (Veronica Driskill)



Seeking services today for management of "gang stalking" and requesting to know how this provider to treat for "gang stalking" and wants the provider to read up on "gang stalking" and attest that the disorder called "gang stalking" is real or he would not proceed with the session. This provider promised to research the said disorder and will be informed enough to discuss it at the next session. Patient became irate, and most of the interval history obtained from his mother. Patient is known to this practice, with diagnoses of schizoaffective and depressive disorders. Patient reported of being stalked/followed and earmarked for destruction. Stated that the stalking drove out of Denver where he had a home onto street and now living with his since 2017.


Reported multiple inpatient psychiatric holds/hospitalizations: Pennsylvania, in 2017, on his way to Washington DC, to discuss the topic of "Gang stalking" with authorities; San Bernardino Comm. Hosp. in 2020; January/2021 - 2 weeks at Arrowhead BMC, Colton, CA; and October/2021 at Canyon Creek Beh. Health, Texas, for 2 weeks.


He identified as a gay man. Patient suicidal thoughts, auditory/visual hallucinations during the session

-history of cardiac issues/events: patient denied

-history of head trauma: patient denied

-history of seizures: patient denied

-history of chronic pain syndrome: patient denied

Review of current DSM-V Symptoms:
Depressive symptoms M/B:
+Depressed mood/sadness
+Anhedonia/Motivation
+Feelings of worthlessness/hopelessness
-Excessive guilty
-Sleep disturbance
-Appetite with weight gain/loss
+Poor concentration/attention

Anxiety/Panic Symptoms M/B:
+Anxiety
+Excessive worries
+Difficulty to control, inability shot down one?s mind
-Easily fatigued
+Difficulty concentrating
+Easily irritability
-Sleep disturbance
-Headache and/or muscle tension
-Eyed up or on edge

Mania Symptoms M/B:
Elevated/expansive mood
Racing thoughts
+Distractibility/impulsivity
+Increased in goal-directed activities
-Decreased need for sleep lasting over 24 hours
+Pressured speech
+Grandiose delusions
-Decreased appetite
+Recent Hospitalization

Psychotic Symptoms:
+Delusions
-Hallucinations
+Disorganized speech
+Disorganized behaviors
+Paranoia
+Negative symptoms

ADHD Symptoms:
Inattention Sx M/B:
patient denied
Hyperactive/impulsivity Sx M/B:
patient denied

PSTD Symptoms M/B:
patient denied

OCD SYMPTOMS M/B:
patient denied

EATING DISORDER SYMPTOMS:
patient denied

SUBSTANCE ASSESSMENT HX:
-cannabis: Endorsed
last used last month
-alcohol: denied
-meth/cocaine: endorsed
onset: age 20
amount: < 1 gm/month
last used: a month ago
-Nicotine use/Vaping: never smoke, per patient


RISK ASSESSMENT:
-Suicidal thoughts: patient denied
-History Suicidal Plan/Attempts: patient denied
-Homicidal Ideation: patient denied
-History of Harm to Others: patient denied
-Access to firearms or other weapon(s): mother endorsed, but locked

-Marital Status/Kids: single with no kids
-Living Situation: living with mom, since 2017
-History of Abuse/Traumas: denied
-Employment/School /Occupational Status: on disability benefits
-Highest Education: 12th grade
-Current or Prior Military Service: denied
-Support/Social Systems/Network: mother and friend (Luis)
-Legal/Forensics Hx: jailed once in Texas
-Religion/Spiritual Belief: Christian
-Sexual Preference: identifies as gay
-Use of Herbal/Nutritional Supplements: denied

Tobacco: Never smoker -
Alcohol: Do not drink -
Drug Abuse: Illicit drug use -
Cardiovascular: Eat healthy meals -
Safety: Household Smoke detector -
Sexual Activity: Homosexual encounters - per patient "I am gay"

Birth Gender: Male -
Custom Items: Cannabis -

mother denied

Eyes: WNL
Ears: WNL
Nose: WNL
Mouth/Throat/Voice: WNL
Neck: WNL
Respiratory: WNL
Cardiovascular: WNL
Gastrointestinal: WNL
Musculoskeletal: WNL
Neurological: (+) difficulty concentrating
Psychiatric: (+) change in mood, (+)depression, (+)sadness interfering with function, (+)anxiety, (+)nervousness, (-)sleep disturbance, (-)suicidal ideation, (+)hopelessness, (+)worthlessness, (-)hallucinations
has a history of HIV

Hyperlipidemia
Type II DM
HIV POSITIVE

denies past surgical history

cariprazine, 1 cap(s) orally at every bedtime (Edited by CHINYERE OBAKHUME on Jan 4, 2022)
lamotrigine, 1 tab(s) orally 2 times a day (Edited by CHINYERE OBAKHUME on Jan 4, 2022)

No allergy history has been documented for this patient.
No known medication allergies

General Appearance/Build: Appeared the stated age of an average built
Grooming/Hygiene: average
Eye contact/Demeanor: erratic
Motor Activity: agitated
Speech: pressured and excessive (dominated the session with irrelevant details)
Mood & Affect: irritable & angry (mood & affect congruent)
Thought Process Disturbances: loose association
Thought Content Disturbances: paranoia "all his discussions were centered on gang stalking"
Perception Disturbance: denied
Behavioral Disturbances: poor impulse control
Attitude towards the Examiner: uncooperative, verbally aggressive, and augmentative
Suicidality/Homicidiality: Denied
Cognition: Alert & Oriented X4 (name, place, day & situation)
Memory: Unimpaired
Judgment/Insight: impaired

Severe mood disorder with psychotic features (disorder) (F31.64/296.64) Bipolar disorder, current episode mixed, severe, with psychotic features modified 6 Jan, 2020

Schizoaffective disorder, bipolar type (disorder) (F25.0/295.70) Schizoaffective disorder, bipolar type modified 6 Jan, 2020

Patient Instructions/Plan

recommended psychotherapy


Medication(s):

Start these medications below:
Refused to restart Risperdal and Depakote and wants to be restarted on Vraylar and Lamotrigine
Declined to sign the med. consent form and mother stated that patient can sign
-Patient informed that dose may be titrated as needed to targeted symptoms relief



-Discussed medication education/risks/benefits/adverse side effects/black box warning in details with patient & mother
-Patient and mother consented to proposed treatment plan with the above medication(s)



Psychoeducation:

-Brief supportive counseling, validation, and supports provided

-Provided education regarding diagnosis, treatment plan, and importance of psychotherapy

-Reviewed medication indications, use, need for adherence to prescribed medication, handling, and storage.

-Balanced nutrition/hydration/participation in physical activity encouraged

-Provided education on sleep hygiene



Safety Plan:

-reviewed safety plan with patient

-ER precaution and/or to call 911 or PMHNP if there are any safety concerns
-mother agrees to monitor for safety and support safety plan
-advised to seek services with the nearest crisis in the event of harm to self or to others


CURES:

Reviewed (1/04/2022)
No concurrent usage of legal/formal high-risk medication(s)

Return-to-Clinic: 2 weeks or sooner if needed

Bipolar Disorder.

54 year old LGBT Caucasian male with Bipolar Disorder & HIV, says he is upset as his car was stolen yesterday but recovered in the evening, thinks it is a part of the gangstalking that he has been complaining about for a while, feels he is still being gang-stalked, otherwise appears calmer, sleeping well, thinking is more organized,

Vraylar has had positive response, Has stopped taking Ativan.
no intention of hurting self or others,
He does not own a gun,

Overweight
Photosensitivity
HTN
DM

Vraylar, 1 cap(s) orally at every bedtime (Edited by MUBASHIR FAROOQI on Jan 6, 2020)
lamoTRIgine, 1 tab(s) orally 2 times a day (Edited by MUBASHIR FAROOQI on Jan 6, 2020)

Physically the patient appeared disheveled. Emotionally the patient appeared angry and anxious. Attitude in the interview consisted of cooperation. Observed behaviours included psychomotor agitation. The patient presented with speech that was normal in rate, rhythm and articulation. Mood was ambivalent and his affect was anxious. The patient's thought process was normal and his thought content consisted of guilty ruminations and obsessions.

Severe mood disorder with psychotic features (disorder) (F31.64/296.64) Bipolar disorder, current episode mixed, severe, with psychotic features modified 6 Jan, 2020

Lamotrigine 200 mg BID, Vraylar 6 mg po qd.
RTC 8 weeks.