Therapy | Therapy | sthomas universty

CHIEF COMPLAINT: Patient is a 14 yo. female who presents today for evaluation of possible eating disorder.

HISTORY OF PRESENT ILLNESS:

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Kelly presents today with her mother, I had the opportunity to speak with the patient alone and then with their parent alone. We then came together at the end of today’s assessment to discuss findings and recommendations.

Kelly states she wanted to change her body shape and size about 3 months ago. Her mother states she started talking about how specific foods with make her “fat” several months ago, but was still eating. About 3 mo ago, she started restricting her intake. She started avoiding sugar and didn’t have cake on her birthday or her mom’s birthday. There are more arguments around food at home. She has lost ~15# in 3 months.

Kelly states she is feeling tor-“I don’t want my organs to shut down like my mom says they will, but I also don’t want to eat more and gain weight”. Kelly hasn’t had a period in 2 months.

Kelly has been struggling with depression. She was seen in the ER in March 2022 for suicidal ideation, but was discharged. Mood has been improved since starting sertraline.

EATING BEHAVIORS:

Overeating/Emotional Eating/Binge Eating: Maybe once or twice recently

Purging: No

Chewing and spitting: No

Restricting food/under-eating: restricting intake

Vegetarian/Vegan: No

Compulsive or excessive exercise: 3-4/wk for 40-50 min. Motivated by wanting to lose more weight.

Diet pills/supplements/weight loss programs: No

iding Food: No xcessively Picky Eater: No axative use: No

ercent of the day the patient spends thinking about food, weight and/or body image: 50-74%- should you really eating this? Maybe you shouldn’t eat all of this?

NEIGHT HISTORY:

Surrent weight:. 44.5 kg (98 lb 1.7 oz) (25 %, Source: CDC (Girls, 2-20 Years))

Current height: 1.661 m (5′ 5.39″ (79 %, Source: CDC (Girls, 2-20 Years))

Highest weight: 112 lb on 3/30/22.

Lowest weight: 98 lb current.

PAST MEDICAL HISTORY:

Past Medical History

Problem List

PAST HOSPITALIZATIONS/SURGERIES/MEDICAL ILLNESSES:

Past Surgical History

CURRENT MEDICATIONS:

Depression. Taking sertraline with improvement in symptoms.

Psychiatric hospitalizations: No. ER visit for SI 3/2022.

Self-harm: N

Suicide attempts: N

Columbia – Suicide Severity Rating Scale (C-SSRS) Score

Wish to be dead

1. In the past month, have you wished you were dead or could go to sleep and not wake up?

Yes

Suicidal Thoughts

2. In the past month, have you had any actual thoughts of killing yourself?

No

Suicide Behavior

6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?

No

Risk Score: LOW

Risk Assessment

Risk Factors: History of mental health diagnosis and Anorexia nervosa (vs other eating disorder diagnosis)

Protective Factors: Family and community support and Close observation by family or friends

Suicide Risk Summary

Based on the patient’s current responses to the C-SSRS, risk and protective factors, and current mental status exam, suicide risk is deemed to be: LOW. The following actions have been taken: Crisis intervention numbers were provided.

FAMILY HISTORY:

Mother with hx of depression and anxiety. Father with history of anxiety. Sister with history of depression and anxiety.

Family history of depression, anxiety, bipolar affective disorder, other mental illness, alcoholism, drug abuse, suicide attempts or eating disorders is otherwise negative.

SOCIAL HISTORY:

Kelly lives with her parents and older sister in MN. She is close with her family. She will be going into 9th grade- she is anxious about going to high school. She attended a small middle school- 11 students, rigorous. Mom states she would compare herself- not smart enough, not thin enough. She plays the violin.

Mom works at OT in a school

History of Legal Problems: no

Religious or spiritual beliefs impacting service preferences: n/a

Alcohol: N

Tobacco: N

Drug use: N

Caffeine: N

REVIEW OF SYSTEMS: Please see scanned intake form.

Menstrual history:

Patient’s last menstrual period was 05/25/2022 (approximate).

12/2022 09:20 Progress Notes Initial Evaluation

Height: 166.1 cm (5′ 5.39″)

Weight: 44.5 kg (98 lb 1.7 oz)

Estimated body mass index is 16.13 kg/m? as calculated from the following.

Height as of this encounter: 1.661 m (5 5.39″).

Weight as of this encounter: 44.5 kg (98 lb 1.7 oz).

GENERAL: Patient alert and oriented, in no acute distress. Cooperative throughout examination.

SKIN: Clear, warm, dry. No rashes. No suspicious lesions.

HEENT: Atraumatic, normocephalic skull. PERRLA. Oropharynx clear. No exudates. Dentition satisfactory.

NECK: Supple, without adenopathy or thyromegaly. No parotid or submandibular gland enlargement noted.

HEART: Regular rate and rhythm. Normal S1/S2. No murmurs, clicks, rubs, or gallops.

LUNGS: Clear to auscultation bilaterally. Normal effort, No wheezes, rales, or rhonchi.

ABDOMEN: Soft, nontender, active bowel sounds, no hepatosplenomegaly or other masses. Nondistended.

EXTREMITIES: No lower extremity edema. No acrocyanosis. Hands and feet warm to touch. Well formed. Moves all extremities equally.

NEUROLOGIC: No focal neurologic deficits. Normal gait.

PSYCHIATRIC: Alert and oriented × 3. Speech volume and pat§r normal. Thought processes coherent and logical.

Normal insight. Judgment intact. No suicidal or homicidal ideations.

EKG: Tracing from today was performed and was independently reviewed. It showed a HR of 66 bpm and QT interval of 419 msec. The EKG was read as: NSR, early repolarization

LABORATORY: Labs ordered and results are pending

ASSESSMENT:

Anorexia nervosa, restricting type – restriction of intake and ~15# with loss over the last 3 mo. Discussed with pt’s mother it is very positive that it was caught so early. Pt has some insight into the dangerous results of restricting intake and wants to avoid these on some level.

Discussed outpatient FBT as the treatment recommendation. Overview provided, signed up for Jumpstart for tonight. If not making progress, will consider HLOC, however parent seems capable and quite motivated to engage in FBT..

Secondary amenorrhea

Depressive disorder

PLAN:

Patient will be admitted to the Park Nicollet Melrose Institute eating disorder treatment programs in level OP.

Patient is considered to be medically compromised, but stable today and interventions will be directed to medical stability monitoring, reduction of eating disorder symptoms, and it improved nutrition. Education regarding medical complications of eating disorders will be provided for the patient, family, and/or support individuals.

Outpatient eating disorder treatment with medical doctor, registered dietitian, and licensed psychologist is recommended for the purpose of medical monitoring, nutrition counseling, and psychotherapy. Goals of curriculum based treatment program include weight restoration, weight stabilization, symptom interruption, medical stabilization, nutrition education, stabilization of eating patterns, and education with family.

Social History:

The patient currently lives with mother, father, and sister.

The patient is currently employed: No. Will be a freshman at Roseville HS

Food and Security

Within the past 12 months, were you worried that your food would run out before you had money to buy more? No Within the past 12 months, has food you purchased run out and you didn’t have money to get more? No Barriers to Recovery: None

Weight History/Patterns: May started reducing the amount of food she was eating each day and exercising more ofte cut back on sugar based foods

“Did not want to be obese”

Was weighing self 1-2 times per day

Does not currently have access to a scale

Current Height and Weight:

08/01/22: 1.661 m (5’5.39″) (79 %)*

* Growth percentiles are based on CDC (Girls, 2-20 Years) data.m

GOALS OF TREATMENT:

Medical stabilization: Yes

Weight restoration: Yes

Weiaht stabilization Yes

Allergies

Problems imm/inj/.

7/12/2022 09:20 Progress Notes Initial Evaluation

Symptom interruption: Yes

Nutrition education: Yes

Stabilization of eating patterns: Yes

Education with family: Yes

CONSULTATIONS:

Psychiatry: For evaluation of psychiatric comorbidities and use of psychotropic medications No

Physical therapy: PT consult for Evaluation of physical performance, functional limitations and exercise instruction with home program: No

Occupational therapy: For evaluation of life skills and safety: No

Chemical Dependency: For Substance abuse issues: No

This plan was discussed with the patient and her family (mother), who verbalized understanding.

Melrose Medical Doctor IT Objectives/Interventions

This patient is considered to be medically compromised, but acutely stable today and interventions will be directed to medical stability monitoring, a reduction of eating disorder symptoms and improved nutrition. Education regarding medical complications of eating disorders will be provided for the patient, family and support individuals”.

Total time 90 min spent obtaining comprehensive history, performing exam, preparing plan of care, counseling/educating patient, coordinating care and documenting today’s visit.

Diagnoses:

1. Anorexia nervosa, restricting type

2. Depressive disorder

Other mental health diagnoses: N/A

Target problems/ Symptoms/Needs as identified in DA:

Eating Disorder Symptoms: restricting and compulsive and excessive exercise

Psychiatric Symptoms

Depression: sad and low energy

Anxiety: Worry

Risk Factors: N/A

Needs/vulnerabilities: N/a

Strengths: Engaged in school, Good family/social support system, Has access to treatment, and Treatment compliant

Patient’s identified recovery goals): “I want to eat on my own with my friends which means I need to change my whole mind set”

Goals: Expected Outcome & Prognosis:

Return to normal functioning

Treatment Plan Objectives: (List objectives directed at reducing symptoms and impairment in functioning, need to be measureable.)

Eating Disorder

GOAL

OBJECTIVE

INTERVENTION

IRAFTIAR

Target Resolution

S

Goals: Expected Outcome & Prognosis:

Return to normal functioning

Treatment Plan Objectives: (List objectives directed at reducing symptoms and impairment in functioning, need to be measureable.)

Eating Disorder

GOAL

Target Resolution

Date

8/22/2023

Eating Disorder.

Exercise in moderation

OBJECTIVE

INTERVENTION

METHODS

Objective: Patient will

CBT-E and FBT

eat three (3) meals and three (3) snacks per day. Patient will identify three (3) coping skills for ED triggers/symptom urges. Patient to

complete self-monitoring record to assist in identifying triggers fas eating disorder symptoms. Patient will discuss triggers for Symptom use and identify coping skills at leach session.

Treatment Details.

Type of Service (duration): 90834 Psychotherapy 45 minutes

Frequency: Weekly W

Duration of Treatment: 5 months

Family/Support System Involvement: Family/Support System will be involved in treatment: Family sessions.

Session 1 as family session

Group guidelines were reviewed, including confidentiality. Verbal consent was obtained.

Skills/ Strategies/ Topics discussed: This one time group therapy session focused on introducing parents to Family-Based Treatment (FBT. Didactic portion focused on educating parents about eating disorders, FBT, and the concept of agnosticism. Charged parents with task of refeeding and recommended goal of 3 meals and 3 snacks. Addressed common questions such as “What?” and “How much?” to feed my child. Explained and encouraged monitoring of meals and other ED behaviors. Broadly explained treatment goals, with a focus on weight restoration and WR. Covered considerations in parents preparing for and prioritizing FBT at home, including work, school, and mobilizing support systems. Questions and concerns were addressed.

Objectives met per I TP: Increase parental skill use and increase support.

Participation: Shares information, shares emotions, listens to others, gives feedback, accepts feedback.

Session #

Assessment and Plan:

1. Anorexia nervosa, restricting type – weight is up almost a pound.

Continue providing 3 meals and 3 snacks. Discussed needing to increase pt’s overall intake- pt’s mom is looking forward to RD appt this week to get more guidance. Encouraged pt’s mom to ask husband for support.

1. Secondary amenorrhea – expect resumption with weight restoration.

2. Depressive disorder

The following plan was discussed and agreed upon with the patient:

. Continue to work on developing and utilizing healthy coping skills and moving away from the eating disorder.

•Encouraged pt to follow up with all treatment providers

Follow up with psychiatry for ongoing medication management

. Continue to update team as needed.

.. Follow up in 1-2 weeks, or sooner prn.

Total time 32 min spent reviewing previous labs, reviewing provider notes from multidisciplinary team, performing exa preparing plan of care, counseling/educating patient, coordinating care and documenting today’s visit.

Session #

VISIT:

Kelly is here with her Mom, Sara today for FBT. Met with Sara individually and she reports things are going well at home. Some resistance to specific foods (I.e. yogurt) but eventually she is eating. She has a call into the school to figure out where Kelly can eat lunch and last week they did a tour of the school. Mom shared it may be difficult to make future appointments at the MG location once school starts due to the commute and video visits don’t work. Expressed my concern with the lag time of school starting and Kelly not starting with her new therapist until November. Mom said she would look at their schedule and see if there is anything they could do.

Met with Kelly and she denies restricting but admits the urges are very big right now. Her ED thoughts are heightened when she eating and then “screaming” at her afterwards. Unable to identify specific thoughts. Discussed coping skills to begin reframing her thoughts. Also using distraction at when she is eating with music, tv, conversation, etc. Encouraged her to track her thoughts at least once per day so we can begin to counteract/reframe.

PRESENTING PROBLEMS/SYMPTOMS:

She presents with Anorexia Nervosa (AN). Symptoms include restricting and over-focus on shape/weight.

MENTAL STATUS EXAM:

Mood: anxious

Affect: mood-congruent

Appearance: age appropriate

Tonic Scores:

Melrose Tonic last three scores:

8/22/2022

Session #

Patient’s progress in treatment:

Weight increase – weight remains stable. Within 1# of GW. Discussed adding more consistent snacks daily to increase caloric intake or increasing portions at meals.

Restricting: Frequency — mom continues to plate/portion meals. Options are given to patient for snacks generally.

Adhering to meal plan – 3 meals/1-2 snacks.

Eating Disorder thoughts – patient shared she no longer wants her eating disorder and noticed a decrease in thoughts ” a couple of months ago”. Reported she no longer sees the benefit of it and it takes too much to maintain.

Poor body image

Patient’s response/participation in today’s session: Patient was engaged in session.

Family’s response/participation in today’s session: Mom shared progress since starting treatment, in phase 2. Shared hopes for patient and places in which patient may be struggling.

Family’s support plan: eating meals together and cooking, prepping, serving meals

Patient’s Treatment Goals: Increase regular or scheduled eating patterns

Weight increase

Improve readiness and commitment to treatment

Increase effective use of coping strategies

Decrease eating disorder thoughts

Express thoughts and feelings

Maintain progress in recovery from eating disorder