Edgardo R.

Main

Sobriety

Claims Sobriety

03/30/2008 - 7/2/08

Cocaine until 2 months ago [dated 5/30/2008](Tr. 256)
this is consistent with alleged multiple month sobriety to physical CE [12/2008](Tr. 434).

See (Tr. 559) 7 days clean as of 7/10/08

Alleged Sobriety

7/4/2008 - 12/18/2008

(Tr. 559)- (Tr. 572)

Last tx record prior to relapse, date of relapse unknown.

Alleged Sobriety

2/15/09 - 4/25/10

Fairmount detox on to relapse

Drug Use

Drug Use

1/2006 - 3/2008

Reported Drug Use

7/2/08 - 7/3/08

"I wasn't showing up because I was using drugs again" I have seven days clean & I need to see a psychiatrist as soon as Possible" (Tr. 559)

Reported Drug Use

10/1/2008 - 10/3/2008

I couldn't deal with the anxiety and desperation I run to use marijuana and cocaine for two days to calm down. Medication isn't helping me, I want to change my life. (Tr. 566)

Reported Drug Use

10/6/08 - 10/7/08

From Psychiatrist: Relapsed on cocaine/heroin last week after 6 months of sobriety. (Tr. 588)

Reported Drug Use

2/10/2009 - 2/11/2009

Unknown when started. Last reported use was 2/11/2009 then into Fairmount after suicidal and homicidal tendencies (Tr. 459) Two bags of cocaine via IV daily (Id.)

Reported Drug Use

4/25/10 - 4/26/10

Reported injects 10 bags of heroin daily and 1 g of cocaine daily (Tr. 532)

4/24/10 urine test from Reading Hospital positive for cocaine and opiates

Symptoms

Suicide Attempt

7/6/06 - 7/7/06

(Tr. 300)

Lack of Sleep, Impulse Control

5/30/2008 - 5/31/2008

I have two months clean of heroin and cocaine and it's too hard. I am very impulsive and aggressive. Sometimes I hate to socialize and prefer to be isolated. I have six days without sleep (Tr. 254)

Complaints & Assessments

7/14/2008 - 7/15/2008

Mental Status Assessment: Normal for most, but agitated and anxious, no suicidal ideation, stable mood, memory good, insight and judgment fair.

Complaints of auditory hallucinations 1 month prior (6/2008)
(Tr. 268-271).

Feeling better with meds, but not sleeping

7/17/08 - 7/18/08

"I am feeling better with the medication, but I still have problems for sleep" I have three days without sleep" I feel more calm down tired but I can't sleep" "I don't trust nobody" (Tr. 560)

Better with Increased meds, but still symptoms

7/31/08 - 8/1/08

"The doctor increased the medication, helps me, but I still with problems. " I don't sleep, negative thoughts, I hear that somebody knock the door but nobody is in the door." "Smoking a lot of cigarettes" (Tr. 561)

Decrease in desire to use drugs

8/7/08 - 8/8/08

Depakote and Remeron are working well but seroquel is causing me only side effects" "my desire of use drugs is less after I start with medication" (Tr. 562)

Sleeping around 3-4 hours (Tr 562)

Continues with negative thoughts, doesn't trust people (Id).

Medication helping, abilify not

8/21/08 - 8/22/08

Depakote and Remoron helping, abilify I have problems concentrating and organizing my thoughts. (Tr. 563)

Client is using medications ordered by psychiatrist (Id.)

Sleeping 5-7 hours during day

9/18/08 - 9/19/08

I can't sleep during the night but I sleep during the day. I sleep like 5-7 hours. (Tr. 564)

Client has gained 22 pounds (Id.).

Therapist congratulated him on the progress he's made (Id.)

Desperate because cannot sleep

9/22/08 - 9/23/08

I am desperate because I can't sleep and I am afraid that something worse can be happening with my health" (Tr. 565)

Feels medication not working as desired (Id).

Not sleeping and can't concentrate

10/16/08 - 10/17/08

I am not sleeping and I can't concentrate" I am anxious and with bad mood most of the time. I don't have my medication and the one I was using wasn't helping me. (Tr. 567)

Recurrent paranoid ideas, one week without meds. Will go to door with knife when someone knocks.

Mood changes from one moment to next

10/23/2008 - 10/24/2008

I feel desperate. I hate that my mood changes from one moment to another. I don't find a place. I am not sleeping. I cannot relax. Everything bothers me. (Tr. 568)

More anxious than usual. (Id.)

Still no medications!

Off Meds, not sleeping, agitated

11/7/08 - 11/8/08

I am not sleeping. I feel constantly agitated, I can't concentrate on nothing. Fighting all time with my desire to use drugs again. (Tr. 569)

Desperate to receive medication and avoid relapse (Id.)

New psychiatrist refused to see him due to drug hx? So still no medication. (Id.)

Back on meds, feeling better

12/3/08 - 12/4/08

I am feeling better only that sometimes I need use 1/2 pill of xanax in the morning and one at night. I am sleeping 5-6 hours at night. Abilify doesn't help. (Tr. 570)

Client is feeling more relaxed (Id.)

Sleeping problems, but more stable

12/8/08 - 12/9/08

I have two days I haven't slept well, only 4 hours. I need to use medication for sleep. I feel I am getting more stable. (Tr. 571)

Client with anxious mood.

Doing Well

12/13/2008 - 12/14/2008

Told physical CE: Previously had suicide attempts, now doing well has no suicidal tendencies. Stopped taking drugs 7 months ago , takes no drugs now.

Sleeping well at night, doing a little better

12/18/08 - 12/19/08

I did a little better in the last week with the use of my medication. I have hope of one day be stable. I am sleeping well at night. (Tr. 572)

Seroquel helping to sleep a night.

Not on medication, increasing anxiety

3/12/09 - 3/22/09

I am not sleeping, and feeling very tired. I need my medication. I feel like urgent necessity of my medication. I feel too anxious. I would like be more calm down as I was before with my medication. (Tr. 574)

Client willing to cooperate with my treatment (Id).

Post Detox: Not sleeping well. Back on Meds

3/14/09 - 3/15/09

I was drinking and I stop my medication and I was on drugs until I went to Fairmount for a Detox. I didn't have the face to look at you [therapist] at that time. I am not sleeping well. I am using my medication again. (Tr. 573)

Increase in anxiety, lack of sleep

4/4/09 - 4/5/09

I am feeling anxious a lot. Everything gets me anxious. During the night I wake up and get more anxious. (tr. 575).

Back on meds, feeling better

4/24/2009 - 4/25/2009

After I restarted use of my medication I have been feeling better. My life is getting stable after the crisis I had. I didn't know if one day I am going to be clean without medicaiton. (Tr. 576).

Client started again the psychotropic medication. Discussed progress after return to medication.

Constantly has mood swings, depression returned

7/23/09 - 7/24/09

During this week I felt worse because depression came back after I was without it for a long time. (Tr. 578)

Suicidal & Homocidal

2/12/2010 - 2/13/2010

302'd after stabbing girlfriend with scissors.

Doing well, but not sleeping, hearing voices

7/4/10 - 7/5/10

Been doing well, but not sleeping well. Taking his sleep medications every day, but they do not work. During the day he gets a lot of anxiety, but the pills are working for him. He hears voices, people waking him up by knocking on the door.

Presents calm and collected, maintains eye contact. (Tr. 609)

Not sleeping well, thoughts racing, anxiety

7/29/10 - 7/30/10

Old meds were not working for him so he went back to his old prescriptions. Not sleeping too well. Wakes up to any small noise. Concentration is ok. Times when he hears people calling his name, noone there. Thoughts are racing. (Tr. 608).

Not sleeping well, meds not working, anxiety

8/13/10 - 8/14/10

I am not sleeping well. He's up to date with his medications but feels they are not working for him. Takes his meds at 7pm, and before they would take effect by 9pm, not happening now. He may have some anxiety. Thoughts and heart racing. Still hearing voices and seeing shadows. (Tr. 607)

Taking meds, doing well, sleeping well, still audio and visual hallucinations

8/27/10 - 8/28/10

Taking his medications as prescribed, been doing well. Informed therapist that he has been sleeping much better. He still wakes up during the night, but goes back to sleep. Continues to see and hear things at night. (Tr. 606).

Upset about changing meds, can't sleep

9/9/10 - 9/10/10

Frustrated with what was happening, upset because they keep changing his meds on him. He did not understand what was happening and wanted explanation. He cannot sleep at night and continues to stay awake and walk back and forth. Wants meds he was on before. (Tr. 605).

Can't sleep, trouble concentrating, forgetful

9/23/10 - 9/24/10

Main concern is can't sleep and continues to wake at night. Constantly eating and gaining weight. Gained 35 lbs. Trouble concentrating and is forgetting things. Continues to hear voices.

Patient is very compassionate, he's friendly and likes to get his point across. Continues to do well and looks great. Staying away from drugs. (Tr. 604).

Problem sleeping, hallucinations, anhedonia

10/7/10 - 10/08/10

Can't sleep, lots of anxiety. Forgets things like the day of the week. Gaining weight, not eating well. Odd dreams, hearing voices, seeing shadows. Checks to see if there are people at the door. Doesn't want to do anything during the day. (Tr. 603)

Lack of sleep, depression, anxiety

10/21/10 - 10/22/10

Not feeling well due to sleep deprivation. Depressed an anxious. He's taking ambien and valum, but not working. He said he did better before the change. Smoking one pack a day, but not drinking coffee the way he was. (Tr. 602).

Not suicidal or homicidal. Not hearing voices or seeing shadows.

Depression increased, loss of concentration, anxiety high

11/4/10 - 11/5/10

Very much anxiety, cannot stay focused on anything he tries to do, he cannot even watch a movie by himself. He gets up and walks around. gained a lot of weight. He is sleeping better thanks to medication. Not homicidal or suicidal. Seems very anxious. His depression is very high. (Tr. 601).

Anxiety Continuing, lack of sleep

11/18/10 - 11/19/10

Now treating at Berks following crisis.

Continues anxiety. Walks continuously back and forth during the night time in his house. Sometimes doesn't want to leave the house, would rather stay home. He reported taking the medication as prescribed. Eating more than usual.

No hallucinations. Well dressed, speaks well, gained significant weight, maintains eye contact. (Tr. 600).

Treatment

Temple Hospital Crisis

7/6/06 - 7/10/06

(Tr. 296- 313)

Diagnosis & Treatment

5/30/2008 - 5/31/2008

Dx. MDD GAF= 55

Northeastern Community Mental Health

5/30/2008 - 10/24/2009

D & T

7/14/2008 - 7/15/2008

Dx: Bipolar, Opiate Cocaine Dependence
GAF 50

Tx: Depakote (500), Seroquel (50 + 100), Rmeron (15?)

Double Remeron & Switch Seroquel to Abilify

8/11/08 - 8/12/08

(Tr. 272)

Increase Depakote

9/8/08 - 9/9/08

(Tr. 272)

Increase Abilify

10/6/08 - 10/7/08

(Tr. 272).

Farmount Behavioral Health

2/15/09 - 2/17/09

Reason unclear (Tr. 448)

Dx & Tx (Friends)

4/26/10 - 5/3/10

Dx: SAD, Bipolar, Opiate withdrawal, Opiate dependence, cocaine dependence

GAF on Admission: 1-10 on discharge 61-70

Tx: Serum Litium

Follow up at Berks County Psych
(Tr. 450)

Excellent Response to Treatment

4/26/10 - 5/3/10

Course in Hospital: Patient had an excellent response to treatment in the hospital. Tolerated tx well and had no adverse side effects. As the hospitalization progressed, the signs and symptoms of the patient's psychotic affective disorder gradually and COMPLETELY remitted. (Tr. 533)

Friends Hospital

4/26/2010 - 5/3/2010

For Suicidal Thinking (Tr. 450- 455)

Dx & Tx (Psych Evaluation Berks Psychiatry)

6/2/10 - 6/3/10

Dx: Bipolar, depression, agression, ADHD

Tx: Continue tx and individual counseling.

Berks Psychiatry

6/3/10 - 11/18/10

Tr. 600-625)

Medical Opinions

PRT

10/22/08 - 10/23/08

Dx: Affective D.O. & Substance Abuse

Mild ADL, Mild SF, Moderate CPP, 1-2 EDs
(Tr. 423)

MSS from Tx (NOT A MEDICAL SOURCE)!!!

12/3/10 - 12/4/10

Would render disabled per VE (Tr. 626-628)