Current Med and Diagnoses Page.

I keep this one page document updated and with me at all times.  I also keep a copy in the front of the kids' 3 ring binders.  Their timelines are too detailed and long to keep printed out. I think of this as a summary.  

It's especially useful to have on hand when I need to fill out a health form for school, admittance forms for a psych hospital or residential treatment center, or new therapist or medical practitioner forms. It's also helpful to give to police officers and to child protective service workers (when we're reported for child abuse by a child who makes false allegations). I've even used it with a child's current provider as a refresher since they wouldn't have time to review my child's chart before an appointment, and that can greatly effect what they suggest/ prescribe. . 

It is amazing to me that people will usually believe information when it is in writing (doesn't seem to matter that I'm the one that wrote it!). If I verbally give the same information about my child, they often treat me like I'm overreacting, overemotional, overprotective, over controlling, have Munchhausen by Proxy...    

Another reason I like having this information in a document, is I don't have to repeat the information in front of my child, which can be a huge trigger for him/ her. 

Kitty Themom (K.) 8/8/13

Kitty Themom (K.) (birth name ___________ _________).  Born ##/##/##.  She is 18 and in 12^th grade.  Placed for adoption in Themom home with her brother, Bear (B.) on 11/06.  K. is Caucasian and Native American (_________ – not a Federally-recognized tribe and K’s father is reported to be full Native American - tribe unknown).  Adoption finalized 3/08. 

_ISD School Diagnoses (4/8/13):  (07) Emotional Disturbance; (08) Specific Learning Disability - Basic Reading skill, Written Expression, Mathematics calculation, Mathematics problem solving; (09) Other Health Impaired

Diagnoses: Neuropsych assessment (04/17/12 – The Center -Residential Treatment Facility)

Axis I:  309.81  Posttraumatic Stress Disorder, Chronic, by history

            296.80  Bipolar Disorder NOS, by history

            314.01  Attention-Deficit/Hyperactivity Disorder, Combined Type, by history

            294.9    Cognitive Disorder NOS (deficits in processing speed, working memory,

executive functioning, and visual memory) - Cerebral Dysrhythmia (TBI) – right temporal lobe. - which controls memory, hearing, understanding language (receptive language), organization, and sequencing.

            995.54  Physical Abuse of Child, Victim, by history

            995.53  Sexual Abuse of Child, Victim, by history

            995.52  Neglect of Child, Victim, by history

            307.6    Enuresis, by history, resolved

Axis II:  799.99  Diagnosis Deferred (R/O Borderline Personality Disorder - Emerging)

Axis III:             Obesity

            327.3    Circadian Rhythm Sleep Disorder / Insomnia (diagnosed 4/13)

564.0   Constipation, chronic

                        Acne

                         Esophoria – an inward deviation of the eyes, particularly when tired

                           (diagnosed 5/12)

Axis IV:   Problems with primary support group

               Social Environment

               Educational

Axis V:  GAF = 35-40 (4/17/12)

Mental Status Examination:  Mood: Stable | Thought Processes: Goal Directed   

                                                 Judgment: Significantly Impaired | Insight: Poor

K’s Emotional/ Social Developmental Age: approximately 6-10 years. 

   Previous diagnosis: 313.89 Reactive Attachment Disorder of Infancy or Early Childhood –                                                 not completely resolved.

11/16/2011 Neuropsych - ____ Center: 

Full Scale IQ -                                   ##       (4^th %ile – Well Below Average),

Verbal Comprehension –             ##    (19^th %ile – Below Average)

Perceptual Reasoning –                  ##      (25 %ile – Average)

Working Memory –                        ##       (3^rd %ile – Well Below Average)

Processing Speed –                      ##      (1^st %ile – Lower Extreme Range) 

7/26/12 Tested for Central Auditory Processing Disorder -scored within normal limits (better than 2 standard deviations below average for an adult - anyone >12 years of age) on 9 of the 11 MAPA subtests administered. She scored below (worse than) -2 SD on the Tap Test and SINCA (right ear) tests.  She is considered at risk for CAPD, but does not have it.  - All information must be presented shortly, simply and concretely in a calm, quiet, environment for Kitty to have maximum comprehension.  Kitty’s ability to handle stressful situations is low, particularly when aggravated by loud, chaotic environment, and she shuts down when overwhelmed. 

Current Psychotropic Meds:  T_____ 1800mg (mood stabilizer), S_____ XR 400mg (atypical antipsychotic), W____ XL 300mg, L____ 250 mg (mood stabilizer), I____ 4mg (regulator for ADHD), A____ 10mg (PRN sleep med), L____ 10mg (allergies).

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8/20/09 – 9/5/09  Neuropsych results from M RTC:  

P300 is absent.  (Means she has ADHD).

Cerebral dysrhythmia (brain damage/injury) in right temporal lobe.  {Temporal lobe controls your: Memory, Hearing, Organization and sequencing, Understanding language (receptive language).

Temporal lobe disorders: Exaggeration of emotions is sometimes seen with disorders of the temporal lobes.  Deep in the temporal lobes is the “limbic system,” a primitive system involved with emotions and memory (and to some extent sexuality).  Disorders here can turn anger into rage, sadness into suicidal depression, or anxiety into panic.  Electrical disorders in this area can result in atypical psychotic symptoms, inappropriate sexual behavior, and unusual fears.  Memory problems are common.  Temporal lobe patients are prone to “bad days” when their behavior is out of character.  They are unpredictable and may become depressed or explosive without provocation.

Right hemisphere disorders:The right hemisphere is important in visual spatial reasoning, visual memory, and organizational ability and pattern perception.  In addition, the right hemisphere is involved in the non-verbal aspects of communication such as facial expression, body language, gestures, and voice inflections.  Individuals who cannot express or comprehend such non verbal signals are at a social disadvantage.  Even with normal language, their lack of non-verbal signals makes their communication dull and ineffective.  If they cannot see patterns of social relationships or communicate effectively they may seem odd and be rejected by peers, resulting in problems that peak in adolescence.  Visual processing problems can produce learning impairments which impair schoolwork in math, science, and other visually learning classes. ~From Neuropsychiatry by Dan Matthew, M.D and Larry Fisher, Ph.D.