2014-06-12

11:00 pm

Patient: RW
DOB: 06/09/63

6/12/14 - 2300 - RN and MD met with patient to discuss plan and medication regime. At this time the plan is for RN to assess patient twice a day and to give him his medication every morning to self-administer throughout the day. If patient needs to travel without RN he can have two days of medication at a time. RN will be in close contact with patient's assistants to arrange daily meetings. RN will report status of patient to MD via telephone on a daily basis.

During initial meeting patient was pleasant and cooperative. Patient agreed to the plan and appears motivated to make positive changes in his life. Patient was able to identify some negative consequences of current medication usage and looks forward to living a healthier lifestyle. Plan is for RN to monitor patient and current medication regime while patient finishes his work commitment in Boston through mid July. Once patient completes work commitment he will begin a medical detox in LA.

Plt41 pg 01

2014-06-13

03:00 pm

6/13/14 - 1500 - Met with patient in his apartment. Patient continues to be pleasant and cooperative. He stated that he initially started taking opiates after some dental work and became dependant on them. Patient is fearful of coming off of opiates but knows it is what he needs to do. Patient also expressed some emotional trauma, which causes him depression and anxiety. Patient given positive reinforcement for reaching out for help at this time. Patient was given his daily medication. Each medication was discussed with patient and he expressed verbal understanding. When asked to turn over all medications that he had in his possession, assistant gave the following medications to RN:

Crestor 10mg #19
Lexapro 20mg #80
Lexapro 10mg #2
Klonopin 1mg #115
Valtrex 1G #15
Nexium 40mg #41
Hydrocodone 10-325mg #2
Oxycodone 30mg #53 and 2 halves
Dilauded 8mg #2.5

Patient also takes Cialis 10mg daily but chose to keep this in his possession.

Patient states that he currently takes Oxycodone 15mg BID and Oxycodone 30 mg at bedtime - Not Oxycodone 30 mg TID as originally reported. Patient also states that he takes Adderall 2.5 - 5mg BID prn, not Adderall 5mg BID as originally reported.

Patient will be given the following medications on a daily basis to self administer:

Azilect 1mg - 1 tab in am
Klonopin 1mg - 2 tabs in am
Oxycodone 30 mg - 1/2 tab BID, 1 tab at HS
Adderall 10 mg - 1/2 tab BID PRN
Lexapro 20 mg - 1 tab in am
Crestor 10 mg - 1 tab in am
Valtrex 1G - 1 tab in am
Nexium 40 mg - 1 tab in am (patient chose to take in am rather than pm)
PrevPac - 1/2 pack BID
Librium 300 mg - 1 capsule BID
Ambien 10 mg - 1 tab at HS

Patient instructed to leave any medication that he does not take in the pill container and give back to RN at the end of each day. Patient expressed appreciation to medical team for coming to Boston to help him. Patient or assistant will check in with RN later tonight to determine when will be a good time to check in this evening after patient finishes work. Report given to MD via text. Report included current status of patient and requested refills of Valtrex and Cialis.

Plt41 pg 01-03

2014-06-13

07:00 pm

1900 - Patient's assistant came to hotel to pick up 2 days worth of medication as patient will be driving straight to NY when finished filming at 0200. Patient will return to Boston Sunday night. Per assistant patient stated that he is "feeling great today". Assistant voiced concern that patient does not have an appetite and his nutritional intake is poor. Suggested Ensure TID. Assistant instructed to tell patient to please call at anytime with any questions or concerns while he is away. Report given to MD via text. Report included patient's status and what medications were given to patient's assistant to take to NY.

Plt41 pg 03

6/14/14 - Patient in NY. Per assistant he is doing well.

Plt41 pg 03

2014-06-15

04:00 pm

6/15/14 - 1600 - Contacted patient's assistants to find out a good time this evening to check in with patient. I was informed patient would not be arriving back to Boston until late tonight and had a 0600 call time tomorrow morning. I offered to see patient last tonight or before 0600 call time tomorrow but it is preferred that I go to the set to see patient tomorrow. Patient does have morning and afternoon medication. Report given to MD via text.

Plt41 pg 03

2014-06-16

08:00 am

6/16/14 - 0800 - Contacted patient's assistant to find out a good time to go to set to check in with patient. Assistant will call around noon to set a time.

Plt41 pg 04

2014-06-16

03:00 pm

1500 - Spoke to RN at MD's office. Crestor, Valtrex and Cialas will be mailed to hotel today.

Plt41 pg 04

2014-06-16

11:00 pm

2300 - Accompanied patient on set today from 1300 - 2200. Patient appeared focused and worked hard throughout the day. After filming patient and RN spent time talking back at the hotel. Patient states that his GERD feels better and he is experiencing less burning in his esophagus and throat. VS WNL BP 122/79 P 76. Patient stated that he is getting a better night's sleep but still wakes up a few times during the night and is able to fall right back to sleep. Patient stated he is having a hard time focusing in the morning and requested increasing his AM dose of Adderrall to 10mg. Report given to MD and Adderrall will be increased. Patient will also be started on Melatonin 20mg tonight. Patient continues to have a decreased appetite. Ensure TID was suggested again and patient is willing to try it. Patient continues to be pleasant and cooperative. Patient was given HS medications and one day of routine meds were left with patient's assistant for tomorrow. Plan was for patient to go straight to bed as he has an early call in the morning. Plan for tomorrow is for RN to go to set to assess patient sometime during the afternoon. Full report given to MD via telephone.

Medications changes today:

Adderall 5 mg AM discontinued
Adderall 10 mg AM ordered
Melatonin 20 mg HS ordered

Plt41 pg 04

2014-06-17

02:00 pm

6/17/14 - 1400 - Checked in with patient's assistant to see when I could check in with patient today. Plan is to meet up with patient this evening on location and attend concert with patient and staff. Ensure was picked up from pharmacy and will be given to assistant when convenient.

Medication delivered to hotel today:
Valtrex 1G # 90
Melatonin 20mg #60
Cialis 10 mg #30

Plt41 pg 05

2014-06-17

11:30 pm

2330 - Accompanied patient, fiancé, assistants and security to concert. Patient was preoccupied as he was performing with other musicians during the concert. Patient appeared in good spirits but I was unable to spend any one on one time with patient to assess him or speak to him about how he is feeling. Daily routine medications were given to assistant for patient to self-administer tomorrow. Assistant informed me that patient took Adderall 5mg in am today rather than Adderall 10mg, which he had previously requested. Assistant was asked to please have patient call MD tomorrow, as he would like to check in with him. Assistant was also asked to pass on RN and MD's numbers to fiancé as we would both like to speak with her and to obtain her input towards patients treatment needs. Tomorrow patient is off from his current film but has to do some voiceover commitments for a previous film. Plan is for RN to check in with assistant in the afternoon to see when a good time to assess patient would be. Assistant was also asked to find a good time when we could get some blood drawn for lab work that MD is requesting.

Plt41 pg 05

2014-06-17

02:20 pm

1420 - Status report given to MD via telephone. MD will be visiting patient June 22 - 24 and would like labs drawn prior to his visit. Information relayed to patient's assistant and asked to suggest some possible lab draw times that would work over the next few days. Call made to RN to find out lab hours and her availability.

Plt41 pg 05/06

2014-06-17

05:00 pm

1700 - RN is available to draw labs on 6/20 between 1400 - 1600 and on 6/21 anytime before 1100. Quest Diagnostics closes at 5pm M-F and noon on Saturdays. Labs must be dropped off during business hours. Lab orders will be faxed to Quest Diagnostics fax # (number) by MD's office. The following labs will be drawn: CBC, Metabolic Panel, Serum H Pylori, PSA, Thyroid functions, Arthritis Panel and Glycohemoglobin.

Plt41 pg 05/06

2014-06-17

08:00 pm

2000 - Patient is back at hotel for the evening. Per assistant, patient is eating dinner and will be going to bed shortly. HS medications were left for patient to self-administer. Per security guard, patient appears more focused and in a good state of mind over the past few days. RN reminded assistant and security that I am supposed to be seeing the patient on a daily basis. Plan for tomorrow is for RN to go to the set, assess patient and spend time speaking with fiancé about her thoughts and goals for patient's treatment.

Plt41 pg 05/06

2014-06-19

12:30 pm

6/19/14 - 1230 - Report given to MD via telephone. The following are medication orders for today:

Discontinue - Lithium 300mg BID
Order - Lithium 300 TID

Waiting to hear from assistant as to what time RN will visit patient on set.

Plt41 pg 06

2014-06-19

05:00 pm

1700 - Reached out to assistant to see when RN should head over to the set. Informed that it would be better if patient were seen back at the hotel when he was finished filming this evening.

Plt41 pg 07

2014-06-19

11:30 pm

2330 - Met with patient in his apartment. Patient stated that he is exhausted from his work schedule but overall is feeling great. States his stomach no longer bothers him although he does have some esophageal discomfort throughout the day. Encouraged patient to cut down on the amount of redbull and coffee that he is drinking. Patient returned the pill containers that he has been given containing his daily meds. It is noted that patient did not take his HS medications on 6/14, 6/15, and 6/17 - MD informed and ordered Lithium BID to continue for 3 more days before increasing dosage. Patient educated on importance of taking prescribed medication on a continual basis and patient expressed verbal understanding. Patient stated that the Melatonin had a good affect and he slept soundly last night and woke up feeling energetic this morning. Patient spoke to MD via telephone and updated him on his status. Patient's routine medications for tomorrow were left with patient for self - administration. Patient took HS meds and was planning on going to bed immediately. Plan is for RN to visit patient on set tomorrow and for labs to be drawn at 1530.

Med Changes:

Discontinue: Lithium 300mg TID
Order: Lithium 300mg TID x 3 days.

Plt41 pg 07

2014-06-20

05:00 pm

6/20/14 - 1700 Went to set to see patient. States he did not sleep well last night but feels it was due to emotional stress. Patient states he has been drinking lots of water today and was able to eat 50% of lunch. Labs were drawn and dropped off at the lab. Results will be faxed to MD's office when available. Patient plans on relaxing and staying in Boston for his next two days off. Plan is for RN to check in with assistant to set up a time to see patient tomorrow. Routine meds for Saturday were left with assistant to give to patient to self - administer.

Plt41 pg 07/08

6/21/14 - Patient is spending the day relaxing with his fiancé in his apartment. Routine medications for Sunday were given to patient's security guard to give to patient for self-administration. Texted patient to set up time to meet with MD tomorrow and did not get a response.

Plt41 pg 08

2014-06-22

09:00 pm

6/22/14 - 2100 - Met with patient and MD. Reviewed all medications, patient's status and plan for detox off opiates when he is finished filming. Patient is in agreement of current plan. Patient states he is sleeping better but feels mildly sedated throughout day and depressed for the past 3 days. Patient feels this is situational rather than related to any medications he is taking. Patient spoke about his difficult childhood and current mood swings. It was explained to patient that once his medications have reached therapeutic effect he should experience increased mood stability and he will be able to benefit more from therapy. Patient states his stomach issues have diminished and he does not have any medical complaints at this time. Patient was given his routine medications for Monday to self-administer.

Medication changes:

Discontinue: Lithium 300mg BID
Order: Lithium 900mg HS
Discontinue Adderall 5 mg in afternoon
Order: Adderall 10 mg in afternoon

Plt41 pg 08

2014-06-23

02:00 pm

6/23/14 - 1400 - Plan was for RN and MD to visit patient on set today. Patient's assistant informed us that the set was very chaotic and patient would like to meet with us tomorrow on his day off instead.

Plt41 pg 09

2014-06-23

10:10 pm

2210 - RN met with patient's security and assistant and was informed that patient and his fiancé will be leaving early morning to go to a Spa for Tuesday and Wednesday. Plan is for MD and RN to meet with patient and fiancé before they leave in the morning. Assistant given patient's routine meds for the next three days to self-administer while he is away.

Plt41 pg 09

2014-06-23

11:00 pm

2300 - Per MD we will only be meeting with patient's fiancé tomorrow.

Plt41 pg 09

2014-06-24

12:00 pm

6/24/14 - 1200 - RN and MD met with patient's fiancé to inform her of treatment plan for patient. Fiancé voiced concerns of patient's behavior while using drugs and alcohol. She is in agreement of treatment plan and supportive of patient's decision to detox after he finishes filming. Fiancé was educated on patient's current medication regime and feels comfortable with treatment he is receiving. She was encouraged to call RN or MD with any questions or concerns that might arise.

Plt41 pg 09

6/25/14 - Patient is away at for the day and will not be seen today.

Plt41 pg 09

2014-06-26

02:15 pm

6/26/14 - 1415 - RN went to set to assess patient. He stated he has been experiencing "jerking movements" in his hands and legs for the past two days and he feels lethargic throughout the day. MD informed and plan is to stop Lithium at this time and see if patient feels better and symptoms subside, Patient informed of medication change and educated that he should feel better within 24 - 36 hrs and asked to report and changes to RN.

Plt41 pg 9/10

2014-06-26

09:15 pm

2115 - Patient's fiancé called. Medication changes were discussed with her and she was asked to remove Lithium from patient's medication box that she was in possession of. Fiancé expressed to RN that she feels patient's "jerky movements" and clenched jaw started when adderall dosage was increased. She was informed that this was a possibility but we should only make one change at a time so we could r/o what was causing side effects. Fiancé expressed understanding. MD informed of fiancé's concerns.

Medication Changes:

Lithium 600 mg at HS discontinued

Plt41 pg 10

2014-06-27

03:00 pm

6/27/14 - 1500 - Per assistant patient appears more alert today. RN will not see patient on set today but will assess him first thing tomorrow morning.

Plt41 pg 10

2014-06-28

09:30 am

6/28/14 - 0930 - Met with patient in his apartment. Patient reports feeling more energetic since discontinuing Lithium. Patient stated others commented yesterday that appeared to be feeling better. Patient states he continues to have some jerky movements of his hands but it seems to be decreasing. Patient educated that side effects could last up to 36 hrs after last dose of medication. VS BP 111/69, P 61. Patient will be going to his island for the next 3 days. He was given MD's number to call on his way to airport to review lab results. Patient and his fiancé were given RN's and MD's email addresses as they stated this was the best way to communicate from the island. Patient was given 4 days worth of routine medications and will self-administer. Patient informed that RN would like to see him on Tuesday to assess how he is feeling. Patient instructed to call, email or text if needed while he is away. Patient's status reported to MD via telephone.

Plt41 pg 10/11

6/29/14 - Patient away with fiancé and did not contact RN. RN spoke with patient's sister and updated her on status of treatment. Sister will speak with patient in the next few days and will update RN and MD on plan for detox when filming is finished.

Plt41 pg 11

6/30/14 - Patient continues to be away and has not contacted RN. Plan is for patient to return last this evening.

Plt41 pg 11

2014-07-01

11:00 am

7/1/14 - 1100 - RN contacted patient's assistant and requested a time to visit patient on set to assess him. Assistant will contact RN after lunch to set up a time.

Plt41 pg 11

2014-07-01

05:30 pm

1730 - Visited patient on set. Plan was to give him a urine drug screen but it was not an appropriate time or place. Patient stated that he feels much better since stopping the Lithium. Stated he could feel when the medication was no longer in his system and no longer has any complaints of jerky movements in hands and legs, no longer feels lethargic during the day and no longer feels "cloudy". Patient states that he is sleeping well at night and feels his mood has improved over the last few days. Patient continues to have poor nutritional intake and does not like the Ensure. Patient is able to eat small portions at a time and is encouraged to try other protein shakes throughout the day. Patient was given daily routine meds for 7/2/14 and will self-administer. Status reported to MD via telephone.

Plt41 pg 11

7/2/14 - Patient has the day off from work and will be spending time with his fiancé and children. Daily routine medications for 7/3/14 given to assistant to give to patient for self - administration. Plan for tomorrow is for RN to visit patient on set.

Plt41 pg 12

2014-07-03

08:30 pm

7/3/14 - 2030 - RN visited set where patient was working from 1100 - 1900. RN spent time with patient's sister who stated she felt her brother was looking and feeling good. Plan of detoxing patient was discussed with his sister and she is going to try to solidify dates and location of detox. Patient was busy filming majority of day and took a 45 min nap during his lunch period. RN briefly spoke with patient and he stated that all is well and had no complaints or concerns at this time. Plan is for patient to travel to his island early tomorrow morning and return last Sunday night. MD notified that urine drug screen has not yet been administered and ordered it to be completed Monday. Routine medications for 7/4/14 - 7/7/14 given to patient's assistant. Assistant will give to patient to self-administer while away. Plan is for RN to visit patient on set on Monday but will be available via phone or email if needed before. Full report given to MD via email.

Plt41 pg 12

7/4/14 - Per patient's sister, patient left for island this morning. He was in good spirits and had no physical complaints. Sister will be flying home today and coming back on 7/7/14 to spend time with her brother and will try to firm up plan for detox.

Plt41 pg 12

7/5/17 - Patient away and did not contact RN.

Plt41 pg 12

7/6/14 - Patient away and did not contact RN. Per security staff patient will return around 11pm tonight and has a 6am call time tomorrow.

Plt41 pg 12

2014-07-07

11:15 am

7/7/14 - 1115 - Waiting to hear from patient's assistant to find out a good time to visit patient on set today to assess him and do a urine drug screen.

Plt41 pg 13

2014-07-07

12:30 pm

1230 - Per assistant filming was cancelled today and patient will be spending the day with his fiancé and children. MD informed and ok'd urine drug screen to be done in the next day or two.

Plt41 pg 13

2014-07-07

09:30 pm

2130 - Saw patient in his apartment. Patient stated he is feeling great. Stated he feels restful after his time away on his island. Patient was relaxing with his fiancé for the evening. Routine meds for 7/08/14 left with patient to self-administer tomorrow. Plan is for RN to visit patient on the set tomorrow.

Plt41 pg 13

2014-07-08

01:00 am

7/8/14 - 1300 - Per patient's assistant it will be a short day on the set today and it would be better for me to see patient tomorrow.

Plt41 pg 13

2014-07-09

07:30 pm

7/9/14 - 1930 - Spent the majority of the day on set with patient today. Urine drug screen completed and results given to MD. MD will discuss results with patient. Patient states that he is feeling great. States he feels he is getting REM sleep every night and wakes up feeling energetic. States he still has a limited appetite but eats "just enough". Plan for detox was discussed with patient's sister and MD. Plan continues to be for patient to finish his work commitment and detox in LA or on his island at the end of July. MD will come to visit patient on 7/14/14 to further discuss plan. Routine medications for 7/10/14 & 7/11/14 left with patient for self-administration.

Plt41 pg 13

7/10/14 - Medications delivered by MD's office:

Ambien 10mg #30
Oxycodone HCL 30mg #15
Adderall 10mg #60
Cialis 10mg #30
Azilect 1mg #30

Plt41 pg 14

7/11/14 - Patient working long hours on set today. RN met up with patient's fiancé and gave her his daily routine medications for the weekend (7/12 - 7/14) for self - administration. Patient will be filming through the night tonight and plans on sleeping all day Saturday and relaxing on Sunday. Plan is for MD to arrive on 7/14 and will discuss next step of treatment with patient.

Plt41 pg 14

7/12/13 - Spoke to patient's assistant and patient is feeling fine and will not need to be seen before the MD arrives on Monday. They will notify RN if anything changes.

Plt41 pg 14

7/13/14 - Checked in with patient's assistant and no changes at this time.

Plt41 pg 14

7/14/14 - MD arrived this afternoon. Plan is for MD and RN to spend time with patient tomorrow before he leaves for work. RN will check in with assistant in the morning to confirm meeting. Routine meds for 7/15/14 given to assistant to give to patient for self-admininstaration.

Plt41 pg 14

2014-07-15

11:00 am

7/15/14 - 1100 - Per assistant patient is in a rush to get to work. Assistant will be in contact later this afternoon to set up a time for RN and MD to visit patient on set.

Plt41 pg 14

2014-07-15

11:00 pm

2300 - RN and MD met with patient. Results of drug test were discussed. The next step in treatment plan is for patient to finish filming and return to la in one week. RN will stay with patient and continue to monitor medications through approximately 8/1/14. At that time patient and RN will go to patients vacation home and will detox in a safe and quiet environment. MD will assess patient prior to detox and will visit patient and RN at his vacation home to assess and supervise detox. Patient is in agreement with plan. Patient was given his daily routine medications for 7/16 & 7/17 to self-administer.

Plt41 pg 15

2014-07-17

12:00 pm

7/17/14 - 1200 - Patient's assistant contacted RN to say that patient would be filming last tonight and has a night shoot tomorrow night. Assistant requested that RN meet up with patient's fiancé to give her patient's routine medications for the weekend.

Plt41 pg 15

2014-07-17

09:30 pm

2130 - Dropped patient's routine medications for 7/18 - 7/21/14 off to his fiancé. Patient will continue to self - administer his medications on a daily basis. Fiancé instructed to call RN if needed over the weekend. Plan is for RN to visit patient on set on Monday.

Plt41 pg 15

2014-07-21

11:40 am

7/21/14 - 1140 - Patient will have a short day on the set today - it will be his last day filming, Plan is for RN to visit him in his apartment when he is finished working for the day.

Plt41 pg 15

2014-07-21

09:45 pm

2145 - RN visited patient in his apartment. He has mixed emotions about filming being finished. States he always gets a bid sad when a project is finished. Talked about future plans and he is looking forward to relaxing on the island in a week or so. Plan is for RN to fly home tomorrow - patient will fly back to LA tomorrow. RN and patient will meet back up in LA on Thursday. Daily routine medications for 7/22 - 7/24 given to patient for self-administration.

Plt41 pg 15/16

2014-07-24

06:00 pm

7/24/14 - 1800 - RN and MD met with patient in his home. All medications were reviewed with patient and no changes will be made at this time. Patient is scheduled for an endoscopy, colonoscopy, lung scan and heart scan on 7/28/14. Preparations for tests were discussed with patient. Prep meds and instructions will be delivered to his home tomorrow. Patient expressed verbal understanding of preparations.

Plt41 pg 16

7/25/14 - Patient's assistant was given prep medications and instructions to deliver to patient today. Patient is aware of his dietary restrictions to start on Sunday morning and to start his prep medications at 6pm on 7/27/14. Patient instructed to call RN or MD if he has any questions or concerns.

Plt41 pg 16

2014-07-27

09:00 pm

7/27/14 - 2100 - RN spoke to assistant and all is set to meet patient at first test tomorrow at 7am.

Plt41 pg 16

7/28/14 - Patient met MD and RN and underwent a colonoscopy, endoscopy, lung scan and heart scan. Initial results came back as non-significant and were discussed with patient. When finals results come in, MD will discuss with patient. Patient was alert and orientated after the tests and was escorted home by his assistant.

Checked in with patient and his fiancé a few hrs after test. Fiance said patient felt fine and had slept majority of day. Patient's assistant given patients routine medications for 7/29 & 7/30. He will give to patient to self - administer.

New Meds Orders as of 7/28/14

Discontinue Crestor 10 mg QAM.

Plt41 pg 16/17

7/31/14 - RN was suppose to meet patient at his studio today but patient slept through recording session. RN met with patients assistant and gave him his rountine medications from 7/31 - 8/4/14. RN and MD will meet with patient on 8/4/14 to discuss detox plan for the island.

Plt41 pg 17

8/4/14 - RN and MD met with patient in his home. MD and patient spoke privately for about an hr. Per MD patient is nervous but continues to be in agreement to detox once we get to the island. Patient was given his routine meds for 8/5 - 8/7. Plan is to leave for the island in the next day or two.

Plt41 pg 17

8/7/14 - Trip to island has been postponed for one more day due to personal issues for the patient. Assistant requested that RN deliver one more day of routine medications to patient in his downtown home. Medications for 8/8/14 delivered to patients security guard to be given to patient for self-administration.

Plt41 pg 17

8/8/14 - Arrived on island today. Plan is for patient to continue to take routine meds through tomorrow at HS. At that time he will not take his Oxycodone and detox medications will be initiated.

Plt41 pg 17

8/9/14 - Patient expressed fears of never feeling normal without his drugs. Reassured him that this is a normal feeling and to just focus on one day at a time and see how he feels on a day-to-day basis. Patient encouraged to be open and honest with how he is feeling physically and emotionally throughout the detox process and assured we will keep his safe and comfortable. Patient took his routine meds today. His HS dosage of Oxycodone was discontinued and replaced with phenobarb 64.8 mg and baclofen 20mg. Patient was also given his routine morning medications minus the discontinued Klonopin and Oxycodone. Patient was left Phenobarb 64.8mg and Baclofen 20mg in addition to morning meds. Patient will self-administer medications. Patient was left with written instructions of what meds he was taking. Patient was also left with an automatic BP cuff and shown how to use machine. Patient encouraged to check BP prior to administering meds and if he starts to feel any withdrawal s/s. Patient expressed verbal understanding and patient's fiancé demonstrated using the BP machine. Patient was instructed to call RN if he needs anything throughout the night. If patient does not need RN throughout the night he was instructed that RN needs to see him 1 hr after he takes his morning medications to assess how he is feeling. MD will arrive tomorrow evening.

New medications orders as of 8/9/14

Discontinue Oxycodone 30 mg - 1/2 tab BID, 1 tab at HS
Discontinue Klonopin 1mg - 2 tabs in am
Start Phenobarb 64.8mg q6-8 hr while awake
Start Baclofen 20 mg QID prn body aches

Plt41 pg 17/18

2014-08-10

01:30 am

8/10/14 - 0130 - Patient's fiancé contacted RN and said patient feels like he needs more "help". Fiancé stated that patient had taken Pheno 64.8mg about 50 min ago. Patient stated his body felt "twitchy". Patient instructed to take Pheno 16.2 mg along with his HS medications and try to go to sleep. Fiancé instructed to let RN know if patient is not asleep within an hr.

Plt41 pg 18

2014-08-10

10:00 am

1000 - MD's flight has been cancelled. Arrangements are being made for him to arrive on the island 8/12/14.

Plt41 pg 19

2014-08-10

01:30 pm

1330 - Per patient's fiancé, patient fell asleep immediately after taking his HS meds and additional pheno and is currently still sleeping.

Plt41 pg 19

2014-08-10

04.15 pm

1615 - Patient awake and states he feels ok. States he is having some cravings but physically he feels better than expected. No s/s of withdrawal noted at this time and no complaints from patient. VS BP 117/78, P 72. Patient self-administered routine morning medications along with Pheno 64.8 mg and Baclofen 20mg. Patient will self administer afternoon and HS medications and call RN if needed. Patient and fiancé educated on all medications and instructed to check BP prior to administering any medications.

Detox orders for today:

Phenobarb 64.8 mg BID
Phenobarb 16.2 mg prn BID breakthrough withdrawal
Phenobarb 80 mg HS
Baclofen 20 mg TID
Neurontin 600 mg BID PRN anxiety / agitation
Clonodine 0.1 mg q6-8 hr prn withdrawal
Zofran 8mg q6h prn nausea
Imodium 2-4mg prn diarrhea, may repeat in 1 hr in needed
Vistaril 25mg prn qHS if still awake 1 hr after routine HS meds

Plt41 pg 19

2014-08-10

06:00 pm

1800 - Patient's status reported to MD via telephone. Additional orders given

Phenobarb 32.4 - 64.8 prn Q3h breakthrough withdrawal D/C phenobarb

Plt41 pg 19

2014-08-10

08:20 pm

2020 - Patient's fiancé reported that patient took afternoon meds at 2000. BP 116/67, P 81.

Plt41 pg 20

2014-08-10

09:15 pm

2115 - Patients fiancé contacted RN to report patient is experiencing runny nose, chills, aches and watery eyes. RN assessed patient and gave prn phenobarb, clonodine and aleve. Contacted MD to bring Motrin when he comes on Tuesday. VS 117/82, P 74.

Plt41 pg 20

2014-08-10

10:10 pm

2210 - Patient states he had some relief with prn meds. VS 116/75, P 72. Patient instructed to take his HS meds between 0100 - 0200 so he can start to get on a regular sleep cycle. Patient and fiancé encouraged to call RN if needed during the night.

Plt41 pg 20

2014-08-11

02:20 am

8/11/14 -

0220 - Patient's fiancé contacted RN. Stated she had given patient his HS meds along with Phenobarb 81 mg and Baclofen 20 mg at 0100. Stated patient is complaining of being in a lot of discomfort - muscle spasms, chills and pains. Instructed to give patient a prn phenobarb 32.4 mg and neurontin 300 mg and to let RN know if it has an affect on patient.

Plt41 pg 20

2014-08-11

03:35 am

0335 - Patients fiancé contacted RN to inform that patient is still awake and continues to complain of discomfort. Instructed to give vistaril 25 mg.

Plt41 pg 20

2014-08-11

04:45 am

0445 - Patients fiancé contacted RN to inform that patient is still awake and complaining of muscle spasms and pain. Instructed to have him take a hot shower and take Neurontin 600 mg.

Plt41 pg 20

2014-08-11

05:40 am

0540 - Patient continues to be awake and complain of muscle spams and pain. RN assessed patient - he had restless legs, muscle twitches, complained of feeling like skin was crawling. BP 124/83 P 63. Magnesium 1 tab and Toradol 30 mg IM administered. Patient encouraged to take a warm shower and did so with assistance from his fiancé. After show patient felt better and restless legs had calmed down. Patient was able to sit still in bed.

Plt41 pg 21

2014-08-11

06:00 am

0600 - Status reported to MD.

Increase pheno to 97.2mg Q4-6h

Plt41 pg 21

2014-08-11

06:15 am

0615 - AM dose of Phenobarb 97.2 mg and Baclofen 20 mg given to patient. Patient was relaxing in bed and felt as thought he could finally go to sleep. RN instructed patient to call when he wakes up in the morning / afternoon. Encouraged him to wake and take his next dose of meds around noon.

Plt41 pg 21

2014-08-12

10:30 am

8/12/14 -

1030 - Per fiancé, patient slept till 1000. Meds given at 1010. VS 117/83 P68. Patient states he feels much better this morning. Medications will be increased today. MD arriving this morning and will assess patient.

New Medicaiton orders:

Phenobarb 120 mg q4-6h

Per fiancé - patient took meds at 1534 VS 112/65

Plt41 pg 21

2014-08-12

05:15 pm

1715 - Patient's fiancé text called and reported patient was c/o headache, deep chills, restlessness and body aches. VS 114/69 P 65. Went to see patient. MD ordered

Motrin 800 mg QID,
Requip .5mg stat and at HS

Patient states he feels better after taking Motrin

Plt41 pg 22

2014-08-12

10:00 pm

2200 - Patient, Fiance, RN and MD had dinner together. Patient was in good spirits and expressed appreciation for RN and MD to treat him on the island. Patient continues to be fearful of who he will be off medications but continues to have a positive attitude toward detox process. Patient had no w/d complaints throughout dinner.

Plt41 pg 22

2014-08-12

10:50 pm

2250 - Patient's fiancé called to say that patient is "not feeling well" and his hands are "twitching bad" - Instructed to give him his HS meds and have him lie down. Fiance instructed to call RN if patient does not fall asleep within 30 min.

Plt41 pg 22

2014-08-13

12:30 pm

8/13/14

1230 - Patient slept through the night. Took his am meds at 1240. RN and MD assessed patient. Hand spasms noted. No meds changes at this time.

Plt41 pg 22

2014-08-13

01:40 pm

1340 - Patients fiancé text to say he wasn't feeling well. MD orders Pheno 64.8 mg, Neurontin 600 mg Stat. Patient and fiancé informed that today and tomorrow will be the most difficult days and to keep in close contact with us.

Plt41 pg 22

2014-08-13

04:30 pm

1630 - Fiancé text to say patients feels much better.

Plt41 pg 22

2014-08-13

05:00 pm

1700 - Fiance text to ask is MD could come to talk with patient privately - stating "something has come up". RN drove MD to meet with patient.

Plt41 pg 23

2014-08-13

06:30 pm

1830 - Patient feels he has a herpes outbreak and is upset that he might have given virus to fiancé. Valtrex increased.

Valtrex 1G TID x2 Day

Plt41 pg 23

2014-08-13

07:30 pm

1930 - Fiancé text to say that patient is emotional over possibility of giving fiancé virus. MD went to talk to him. Patient feeling much better after discussion.

Plt41 pg 23

2014-08-13

08:40 pm

2040 - Fiance text to say that patient was feeling "heeby geebies" - Intsructed to next dose of detox meds. (pheno 4, neurontin 2, baclofen)

Plt41 pg 23

2014-08-13

11:15 pm

2315 - HS meds given - no complaints at this time.

Plt41 pg 23

2014-08-14

12:30 am

8/14/14

0030 - Fiancé tex to say that patient complaining of "cramp, bloating. Instruced to give Bentyl 20 mg. VS 116/56. Fiance instructed to call RN if patient still awake in 30 min.

Plt41 pg 23

2014-08-14

11:20 am

******1120 - Fiancé text to say that patient feels much better. AM meds given at 1030, VS 117/76

Plt41 pg 23

2014-08-14

03:15 pm

1515 - Fiancé administered afternoon meds. VS 115/70. States patient is feeling great today.

Plt41 pg 23

2014-08-14

04:00 pm

1600 - MD spent time with patient.

Plt41 pg 23

2014-08-14

10:00 pm

2200 - HS meds given 99/66 - Clonodine held.

Plt41 pg 23

2014-08-14

11:50 pm

2350 - Text from fiancé that patient is "jonesing" - Instructed fiancé to give patient HS meds.

Plt41 pg 24

2014-08-15

01:30 am

8/15/14 -

0130 - Text from fiancé that patient is "paranoid" and trying to fight with fiancé. States he is "angry" and "freaking out" - RN and MD went to assess patient.

Plt41 pg 24

2014-08-15

02:00 am

0200 - Seroquel 25mg, Pheno 96.4mg, Toradol 45mg IM, given and patient escorted to bed.

Plt41 pg 24

2014-08-16

10:30 am

8/16/14 -

1030 - Per patient's fiancé patient woke up and was feeling restless. AM meds were given and patient fell asleep.

Plt41 pg 24

2014-08-16

02:00 pm

1400 - RN and MD assessed patient and administered meds

Plt41 pg 24

2014-08-16

05:00 pm

1700 - RN and MD assessed patient and administered meds

Plt41 pg 24

2014-08-16

08:00 pm

2000 - RN and MD assessed patient and administered meds. Current med regime is keeping patient comfortable.

Med Changes:

Pheno 64.2 Q4H
d/c Clonodine 0.1mg
Neurontin 300 TID, 600 HS
d/c Requip 1 mg
Seroquel 12.5 TID, 25mg HS

Plt41 pg 24

2014-08-16

11:00 pm

2300 - Patient feel asleep at 2200 - Missed his HS medications.

Plt41 pg 25

2014-08-17

08:30 am

8/17/14

0830 - Patient awake VS 132/82 P 82. RN and MD assessed patient. Patient is social but appears guarded. Discussed med changes with patient and he is on board to continue taper.

Phenobarb 64.2 TID
Seroquel 25mg BID, 50mg HS

Plt41 pg 25

2014-08-17

02:00 pm

1400 - Patient called to ask if we were tapering him today. Reminded him that he got the same dose this am but we are spreading the dose out. Patient stated he was ok to wait till dose.

Plt41 pg 25

2014-08-17

03:45 pm

1545 - Patients fiancé came to get MD and RN stating that patient was erratic and paranoid. RN and MD found patient sitting quietly on his porch. Patient was calm and stated he was frustrated with the process of detoxing. Stated he thought he should be feeling better by now. RN and MD sat with patient and listened to his express his frustrations with how he was feeling physically and emotionally. Patient reassured that what he is feeling is part of the process. Patient stated he wanted to speed the process up and it was agreed between patient and treatment team that we should go back to LA tomorrow and start the next stage of patient's treatment.

Plt41 pg 25

2014-08-18

01:00 am

8/18/14 - 0100 - text from fiancé that patient is upset and irritable. MD and RN went to assess patient. He states he had a fight with fiancé and is questioning whether or not he can emotionally and physically handle detox. Complains of agitation and nausea. RN and MD gave patient emotional support. MD ordered:

Seroquel 100mg - STAT
Phenergan 100 mg IM - STAT

Patient was escorted to bed. Plan is to leave the island tomorrow.

Plt41 pg 25/26

2014-08-18

09:00 am

8/19/14 - 0900 - RN and MD went to check in on patient. Patient is still agreeing that it is best to leave the island but is unsure if he wants to continue detox when he arrives back to LA. MD sat with patient and discussed all the benefits of continuing treatment. AM meds administered. Plan is to leave the island at 1800.

Plt41 pg 26

notes say date is 8/19, but has to be 8/18

2014-08-18

03:00 pm

1500 - Patient's fiancé administered afternoon dose of medications.

Plt41 pg 26

notes say date is 8/19, but has to be 8/18

2014-08-18

06:30 pm

1830 - Upon leaving the island patient appears to be in good spirits. He states that the med combination that he is on making him comfortable and he agrees to continue treatment once back to LA.

Plt41 pg 26

notes say date is 8/19, but has to be 8/18

2014-08-18

09:30 pm

2130 - Patient complains of body aches - evening dose of medications administered.

Plt41 pg 26

notes say date is 8/19, but has to be 8/18

2014-08-18

11:35 pm

2335 - Arrived back in LA. Patient was social for 1/2 the flight home and then rested for the last 1/2 flight home. Upon arrival at LAX patient and fiancé head back to house downtown. Fiancé was given patient's HS meds and AM meds for 8/20/21. Plan is for RN to see patient in the morning.

Plt41 pg 26

notes say date is 8/19, but has to be 8/18

2014-08-19

01:35 am

8/20/14 - 0135 - Patient's fiancé text that patient took HS meds at this time. BP 122/78

New Med Orders:

Lamicatal 6.25mg QD

Plt41 pg 27

notes say date is 8/20, but has to be 8/19

2014-08-19

09:15 am

0915 - RN received text from patient's fiancé - patient self - administered medications at 0915 - BP 134/79. Fiancé states, "he feels great." Plan is for RN to see patient at 4pm.

Plt41 pg 27

notes say date is 8/20, but has to be 8/19

2014-08-19

04:30 pm

1630 - RN saw patient in his downtown home. He was in good spirits and denied any w/d s/s at this time. States he is glad to be home and back on track. Patient educated on new medications and warned of possible side effects. Patient was off to see his daughter on her fist day of filming. Plan is for RN to move into a hotel close by and will see the patient on a daily basis and leave medications for one day at a time. Patient and Fiancé instructed to call RN if needed at any time.

Plt41 pg 27

notes say date is 8/20, but has to be 8/19

2014-08-19

09:35 pm

2135 - Received text from Fiancé saying that he is "feeling it but doesn't want to go to bed yet". Fiancé instructed to give Pheno 64.8mg now and patient can take the rest of HS meds when he is ready to go to sleep. Patient also complains of body aches at this time. Motrin 800 mg given.

Plt41 pg 27

notes say date is 8/20, but has to be 8/19

2014-08-19

11:15 pm

2315 - RN received text from fiancé stating "he's manic, full on flipping out, give up, not to call you guys". Instructed to give HS meds and additional Seroquel 50 mg and to call if RN needs to go assess patient.

Plt41 pg 27

notes say date is 8/20, but has to be 8/19

2014-08-20

12:10 am

8/20/14

0010 - RN received text from fiancé stating, "he seems calmer, not as crazed".

Plt41 pg 27/28

2014-08-20

08:20 am

0820 - RN received text from fiancé stating, "we need help, he's at the border, refusing to take his meds." Fiancé informed RN would come right over.

Plt41 pg 28

2014-08-20

12:30 pm

1230 - RN and MD spend time talking with patient. Patient expressed frustration with the detox process and with not liking how the phenobarb was making him feel. Initially, he stated he was done with the process and no longer wanted MD and RN's services. After processing his feelings and realizing how far he had come and that part of his wanting to give up was due to tension between him and his fiancé. Patient, Fiancé, RN and MD came up with a plan for Fiancé to take a few days for herself and patient was willing to continue treatment but was going to refuse Phenobarbital from this point forward. Patient took AM medications except Phenobarbital at 1020 RN and MD informed patient of the dangers of stopping medication abruptly and offered to shorten the taper but patient refused to take pheno all together. Patient requested Xanax for breakthrough anxiety while going off pheno abruptly. MD agreed to prescribe Xanax 0.5 #15 and patient could keep in his possession as long as RN could randomly count meds to see how many he had taken.

New Medication Orders

D/C Phenobarbital 64.2 TID
Xanax 0.5 mg - 1-2 tabs prn q4-6 h severe anxiety. May keep on person.

Current Med Orders:

Cialis 10gm QD
Valtrex 1G QD
Nexium 40mg QD
Lexapro 30mg QD
Neurontin 300 BID, 600mg HS
Neurontin 100 mg prn anxiety q4-6h
Adderall 10mg BID
Seroquel 25mg BID, 50mg HS
Ambien 10mg QHS
Melatonin 20mg QHS
Bently 20mg prn BID abdominal cramping
Motrin 800mg prn TID pain
Toradol 60mg IM prn Q8h pain
Immodium 2mg prn diarrhea
Xanax 0.5mg prn Q4-6h severe anxiety


Patient may self-administer all medications with the exception of Toradol IM.

Plt41 pg 28/29

2014-08-20

03:00 pm

1500 - Patient agreed to have RN stay with him throughout the day / evening to monitor how he would feel after stopping the Phenobarbital abruptly. Patient complains of increase anxiety but is not requesting prn medication. Stating he wants to sit with feelings and see if he can work through them. Patient given positive reinforcement for behaviors.

Plt41 pg 29

2014-08-20

04:10 pm

1610 - Afternoon meds administered. VS 137/98 P62. Patient c/o body aches - Toradol IM given

Plt41 pg 29

2014-08-20

07:30 pm

1930 - Patient continues to have a diminished appetite. Ate 25% of pasta dinner.

Plt41 pg 29

2014-08-20

09:05 pm

2105 - Patient starting to fall asleep on the couch. Administered HS meds.

Plt41 pg 29

2014-08-21

01:30 am

8/21/14 - 0130 - Patient continues to sleep soundly on the couch.

Plt41 pg 30

2014-08-21

03:15 am

0315 - Patient continues to sleep soundly on the couch.

Plt41 pg 30

2014-08-21

05:45 am

0545 - Patient awake, reading on the couch. No complaints at this time.

Plt41 pg 30

2014-08-21

07:00 am

0700 - AM meds administered. Patient states he is feeling less groggy since stopping the pheno and can feel his mind becoming clearer. Patient states he is determined to be sober and is glad that he has now stopped all detox medications.

Plt41 pg 30

2014-08-21

07:45 am

0745 - Patient ate 25% of English muffin for breakfast. C/o body aches - Toradol IM given.

Plt41 pg 30

2014-08-21

01:40 pm

1340 - Patient continues to have a positive attitude towards sobriety. He has called a sober friend for support and feels it was helpful to speak with someone who understands what he is going through. Patient encouraged to reach out to other sober friends and set up some accountability for his sobriety. Patient's sister has come to spend the day / night with him. Patient was given meds for the remainder of the day and for tomorrow morning and instructed to check in with RN. RN will be close by at a hotel if needed.

Plt41 pg 30

2014-08-21

08:10 pm

2010 - Received text from patient that he has been chatting with his sister all evening and is really enjoying how he is feeling. Patient encouraged to call RN at anytime during the night if needed. If not, to call RN when he awakes in the am.

Plt41 pg 30

2014-08-22

07:30 am

8/22/14 - 0730 - Received a text from patient's sister Christi that patient took his afternoon meds at 1600 and HS meds around 0130 and was asleep by 0210. She stated that patient had an appetite and ate a sandwich late last night. Per sister patient took Xanax 0.5 mg around 1700. Per sister, patient continues to sleep at this time.

Plt41 pg 30/31

2014-08-22

09:30 am

0930 - Received text from sister that patient is up and has taken his AM medications. Sister asked to tell patient that RN would be by in about an hour to see him.

Plt41 pg 31

2014-08-22

10:20 am

1020 - Arrived at patient's house and he is in good spirits. Patient refused breakfast as he stated he still not does not have an appetite.

Report given to MD via telephone. New med orders:

D/C Lamicatal 6.25mg QD
Start Lamicatl 12.5 mg QD x 7days.

Plt41 pg 31

2014-08-22

02:00 pm

1400 - Patient c/o body aches and abdominal cramping. Torordol 60 mg IM and Bentyl 20 mg PO administered.

Plt41 pg 31

2014-08-22

03:20 pm

1520 - Patient c/o diarrhea. Given bottle of Imodium to self - administer as needed, Patient took Imodium 4 mg at this time. VS 141/78 P95.

Plt41 pg 31

2014-08-22

08:20 pm

2020 - Plan is for patient to spend the weekend at his children's house. Per MD okay to given patient his routine meds to self - administer throughout the weekend. Patient asked to touch base with RN throughout the weekend and reminded to stay on a regular sleep schedule. Plan is to see patient when he returns to his home Sunday evening.

Plt41 pg 31

2014-08-23

10:25 am

8/23/14

1025 - Received a text from patient that "all is well".

Plt41 pg 31/32

2014-08-23

07:40 pm

1940 - Checked in with patient via text and got a response, "been very good, I am still a raw nerve and, of course, the receptors are buzzing with electricity." Per text patient plans on having dinner out with some friends tonight and will check in tomorrow.

Plt41 pg 32

2014-08-24

11:25 am

8/24/14

1125 - Checked in with patient via text message. Plan is to see patient later this evening to see how he is doing and to give him his routine medications for tomorrow to self-administer.

Plt41 pg 32

2014-08-24

06:30 pm

1830 - Plan is to meet patient at his house around 2000.

Plt41 pg 32

2014-08-24

07:30 pm

1930 - Patient text to say that he was staying with his kids longer than expected and would let RN know when he was headed back to his house.

Plt41 pg 32

2014-08-24

09:30 pm

2130 - Patient text RN to say that he needed to increase his Valterx. Patient instructed to use the ointment given to him on Friday to self-administer. Patient stated it was at his house, not with him. Call to MD to report patient status.


New Medication Order:

d/c Valtrex 1G QD
Start Valtrex 1 G TID

Plt41 pg 32

2014-08-25

10:00 am

1000 - Met patient at the house of his children and gave him Acyclovier Ointment. New Medication Order - Acyclovier Ointment 1% - Apply as needed up to 3x per day. Patient stated he was enjoying spending time with his children with a clear mind. He took his daughter shopping and the spa and took his son to a comedy show. Plan is for patient to visit his daughter on set today and then meet with RN, MD and fiancé at 1600. Patient given his routine meds for 8/25/14 and 8/26/14.

Plt41 pg 33

2014-08-25

07:00 pm

1900 - Meeting at MD's house was quite stressful for patient. Him and his fiancé are having a hard time communicating and understanding each other's point of view and feelings. A few times during the meeting patient wanted to give up process and talked about going out and relapsing. Per MD stat order - patient was given prn dosage of Neurontin 600mg and Seroquel 50 mg to help with his anxiety. Patient was able to talk through his feelings and agreed to stay working with treatment team. Plan is for fiancé to start therapy tomorrow, patient will continue with current treatment plan through movie shoot and start individual therapy as soon as he is back in LA. By end of meeting patient and fiancé were emotionally stable and agreed to go home and have a relaxing night and not to continue discussion while alone with each other. Patient will call MD or RN if needed throughout the evening.

Plt41 pg 33

2014-08-26

01:00 pm

1300 - Visited patient in his home. He stated last night was peaceful and he fell asleep early on the couch and had a good nights sleep. Stated him and his fiancé had no further discussions about relationship and just enjoyed each others company throughout the evening. Patient given routine meds for 8/27/14 for self-administration. Plan is for patient to go play music with his friend this evening; he will call RN if needed.

Plt41 pg 33/34

2014-08-27

09:00 am

8/27/14 - 0900 - Received text from patient's sister that patient had been recording music with his friend till 0500 and did not go to sleep till 0700 and is currently still sleeping. Sister stated that patient and his fiancé has a disagreement last night and that patient was able to remain calm and handled situation appropriately.

Plt41 pg 34

2014-08-27

01:30 pm

1330 - Patient awake and self-administered routine morning medications. Patient expressing feeling about argument with fiancé and feels relationship is putting unwanted stress on him right now. Patient given positive reinforcement for recognizing triggers and some healthy coping mechanisms for stress were discussed. RN counted patient's Xanax and he has taken #9 tabs since prescription was filled on 8/20/14. Patient reminded that the Xanax as only to be used when his anxiety reach 8/10 and he should use alternative methods of stress relief before taking medication. Patient expressed verbal understanding.

Plt41 pg 34

2014-08-27

04:00 pm

1600 - Patient off to play music with friend and will self-administer routine afternoon medication.

Plt41 pg 34

2014-08-27

09:30 pm

2130 - Patient back home. Per patient he had a long conversation with fiancé and they both understand that right now is a time to work on themselves as individuals. Patient's fiancé now has a RN to help her anxiety and to monitor her while starting a new mood stabilizer medication. Patient feels this will take some stress of their relationship and in return take some stress off of him. Patient is in good spirits. Plan is to leave for London this evening.

Plt41 pg 34/35

8/27/14
RN has been hired to provide private nursing care for client Amber Heard. (Amber Heard will hereafter be referred to as "client" or "AH"). Amber's fiancé, Johhny Depp (hereafter referred to as "JD") is currently under the care of Dr. David Kipper and is attended to by private nurse Debbie. L., RN. This RN will attend to AH while traveling with her fiance to London, UK for his work. JD is a film actor and plans to be working in London for several months. Client AH is also an actress and model, but does not have any work planned for the duration of JD's work trip to London.

Client history:
AH is a 28 year old female. Current occupation is actress and model. She has been in a relationship with JD since 2012. AH and JD met in 2010 on a film set but did not start dating until 2012. Client reports a strong support system, with her sister Whitney living with her in Los Angeles, and "several best friends" that she socializes with frequently. Both parents are living and married, and live in Austin, Texas. Client states she moved from Austin, Texas to New York City when she was 17 to pursue a career in modeling. She moved to Los Angeles in her "early 20's" to continue her modeling career and to pursue an acting career. Client states she works on 1-3 films per year on average, and spends free time volunteering at The Art of Elysium. She has two pet dogs named Pistol and Boo that travel with her frequently. AH reports history of substance abuse, including an addiction to cocaine and liquor. Ct reports abstaining from cocaine "for a couple years" but was unable to report exact dates. Ct does not smoke cigarettes. She reports consuming 1-3 glasses red wine each day. She reports familial history of substance abuse; both mother and father have abused and become dependent on stimulants (methamphetamine), opiates, and alcohol. Her fiancé JD has history of polysubstance abuse and completed a medical detox in July 2014. He has abstained from all substances since the detoxification period. Client admits to history of anxiety, eating disorder, Attention Deficit Disorder, Bipolar disorder, codependence issues, and occasional insomnia. Client identifies as bi-sexual, and was married to female partner prior to current relationship with fiancé.

Per report from JD, Debbie, RN, Dr. Kipper, client AH has reportedly been experiencing increased anxiety and agitation recently, and has had several outbursts of anger and rage. Her mood has been labile. Both client and fiancé JD report an increase in verbal disagreements resulting from client's anxiety and emotional lability. Client expressed concern to husband and Dr. Kipper that she is nervous about being alone while husband is working (on movie set in London) and expressed she has difficulty dealing with feelings of insecurity and jealousy when not in presence of her husband. RN will serve as a companion for client, and will monitor current prescribed medication as well as the introduction and titration of mood stabilization medication. She is a current patient of Dr. Kipper and will remain under his care. Ct has begun bi-weekly individual therapy sessions with Dr. Cowan, and will continue therapy sessions via Skype while in London.

RN met ct and her husband JD at their home in Los Angeles at 2130. Ct is smiling, laughing, eye contact good. Appears calm, comfortable, relaxed, mildly fatigued. Ct and RN start to build rapport. Ct consumes 2 glasses red wine. Current medications include Neurontin 100mg po TID, Neurontin 300mg po qhs, Provigil 200mg po bid, Melatonin 20mg po qhs. Ct will begin Latuda 20mg po qam on 8/28/14 for mood disorder. Ct pleasant with minimal interaction with RN during evening and while arriving on private jet. Plan is to fly to London through the night. Ct self-administered HS medications with the addition of Ambien 10mg at 0030 on 8/28/14. Retired to bed at 0115.

Plt46 pg 01/02

2014-08-28

02:30 am

8/28/14 - 0230 -On plane flying to London. Patient self administered routine HS medications 1hr ago and fell asleep at 0210.
*Time change now 8 hrs ahead

Plt41 pg 35

2014-08-28

06:00 pm

1800 - Landed in London. Patient self-administered routine AM medications. Patient slept about 5 hrs on plane. Complains of body aches and neck tension. PRN Toradol 60 IM given with good effect.

Plt41 pg 35

2014-08-28

10:30 pm

2230 - Patient and fiancé are settling into hotel. Patient was given routine medications for 8/29/30 that he will self-administer. He is ordering dinner to eat in hotel. Plan is for RN to see patient at 1030 tomorrow morning before he leaves for work.

Plt41 pg 35

8/28/14
Landed in London at approximately 1800. Ct states she slept for duration of flight and "feels refreshed." No anxiety noted or reported by ct. Ct self-administered AM medication as scheduled upon landing. RN gave ct daily HS medications and was also provided with Ambien 10mg for sleep. Latuda was not initiated due to flight time and time change, as client and RN arrived in London during the evening, RN will begin Latuda administration tomorrow. Ct's appetite is good, fluid intake adequate. Ct's mood stable, no anxiety noted. RN and Debbie, RN staying in rooms directly across from clients AH and JD in hotel. RN reassured ct to notify her during the night for any needs. Ct expressed appreciation of having RN available on trip. Dr. Kipper notified of ct's status and reason for Latuda not being administered.

Plt46 pg 02

2014-08-29

10:45 am

8/29/14
1045 Ct awake, OOB. Appears calm. Hygiene good. Ct maintains good eye contact, speech normal and logical. Ct consumes coffee and small amount of pastry. States she slept soundly through the night. Reports feeling "fine" but requests to decline Neurontin 100mg po QAM as routine medication as she feels it causes morning lethargy. RN will discuss with Dr. Kipper regarding ct's request. RN reviewed all medications, administration times, and side effects with ct. Ct verbalizes understanding. Ct was provided with pill box containing daily medication divided by administration time. Latuda 20mg initiated for AM dose. RN will fill weekly pill box and review with ct this evening. Ct is grooming self and plans to shop and sightsee today. No anxiety noted at this time.

Plt46 pg 02

2014-08-29

11:00 am

8/29/14 -

1100 - Patient is awake and preparing for his first day of work. He is pleasant and social. Patient self-administered AM medications and a prn Motrin 800 mg for body aches. Patient did not take his Seroquel 25mg this am as he wanted to see how he felt without it as he has some concerns of sedations while having to work. MD notified. Plan is for patient to touch base with RN this evening when he arrives back to hotel.

Med orders:

d/c Valterex 1G TID
Valtrex 1G BID

Plt41 pg 35

2014-08-29

02:00 pm

1400 Dr. Kipper updated on ct's status via email. Per Dr. Kipper's request, RN will discuss need for steady state of medication (Neurontin) in ct's system to keep anxiety level minimal. RN will discuss possibility of reducing AM Neurontin dose to 50mg instead of 100mg, or possibly changing Neurontin dosing schedule to q6-8hrs. RN will also discuss ct's plans to continue communicating with therapist, Dr. Cowan.

Plt46 pg 02

2014-08-29

11:30 pm

2330 - Per patient's security, patient had a good day at work and is now home preparing for bed.

Plt41 pg 36

2014-08-29

11:45 pm

2345 Client, RN, and Debbie, RN went to dinner together. Ct demonstrates good appetite. Drinks 2-3 glasses red wine. No water consumes as ct "prefers only bottled water." RN encouraged ct to adequately hydrate upon returning to hotel where bottled water is available. Ct agrees to do so and verbalizes understanding for necessity of adequate hydration especially due to dehydrating effects of wine and also medication regimen. RN also educates client that alcohol intake can effect prescribed medication, including new medication Latuda. Ct states she understands but continued to consume wine. Ct discussed individual and couples therapy with RN and states she "looks forward to it." 1:1 emotional support and positive reinforcement given. Ct verbalizes feelings of confusion as she feels fiancé would like her to decrease/eliminate acting career and stay at home. Ct wishes to continue working and expresses feelings of fulfillment from career. Ct will have individual therapy session with Dr. Cowan tomorrow at 1800, and RN encouraged her to discuss feelings with him. RN discussed Neurontin with ct per prior request. RN educated ct on necessity of steady blood level of medication for maximum effectiveness, along with ct's typical wake/sleep schedule. Plan was determined to administer Neurontin q 6-8hr. Ct will take Neurontin 100mg an hour after waking, then Neurontin 100mg 6-8 hr after first dose, then Neurontin 300mg at bedtime. Ct verbalizes understanding and is agreeable to this plan. RN offers to notify ct at administration times to assist in establishing medication schedule, but ct declines stating, "it's ok, I will remember." Dr. Kipper is made aware of Neurontin dosing administration change. Ct appeared to enjoy socializing with both nurses during evening. Ct's mood has remained stable throughout day. She responds well to positive reinforcement along with distraction and relaxation techniques. Ct verbalizes desire to increase exercise and to specifically start yoga. RN will continue to encourage ct to achieve this goal. RN offered to provide ct with three day's worth of medication in case she would like privacy during the weekend. Ct declined and took only the pill box for tomorrow. Ct states, "it's ok, you are nearby and I'd like to see you anyway." Ct has bedtime medication with her and has retired to room.

Plt46 pg 02/03

2014-08-30

12:30 pm

8/30/14 -

1230 - Patient text RN at 1015 stating he had a HA. Patient assessed - Toradol IM 60mg administered LUOQ at 1030 with good effect. Patient stated he had a good day at work yesterday and could tell he was more creative now that he is no longer taking opiates. Patient stated he felt fatigued in the afternoon and requested in increase Adderall while he is filming over the next month. Patient reminded he might just be feeling jet lagged and to see how he feels over the next few days. Patient also complains about tension in his shoulders and neck. RN suggested getting a massage today. Patient self-administered routine AM medications at 1115. Plan is for patient to read script for a while and possibly get a massage later this afternoon. Patient will check in later. Patient status reported to MD via email.

New Medication Order

Aderall 10mg 1/2 - 1 tab daily prn lethargy

Plt41 pg 36

2014-08-30

09:30 pm

2130 - Patient text RN to say that he was going to dinner with his fiancé and was feeling pain and tension in his neck. Assessed patient and Motrin 800mg and Baclofen 20mg was given with good effect. Patient stated he had self-administered his afternoon meds around 1500. Patient instructed to call RN during the night if needed. If not needed to text when he wakes up so RN can check in.

Plt41 pg 36

8/30/14
Ct slept soundly throughout night and woke at 1245 today. Ct alerted RN upon waking and self-administered Latuda 20mg and Provigil 200mg at 1300. RN encouraged ct to take Neurontin 100mg at 1400 and 1900 per plan agreed upon yesterday to take q6-8hr. Ct notified RN upon self-administering Neurontin 100mg at 1415. Ct self-administered Provigil 200mg at 1530, then required reminding to take second dose of Neurontin 100mg, which was self-administered at 2110. Ct states she plans to wake earlier tomorrow and will space Neurontin 100mg dosages more evenly. Ct has rested throughout day in her room. Ct requested and was given Motrin 800mg at 1800 for menstrual cramps as her cycle began today. States Motrin was mildly effective at 2000. RN provided ct with additional ibuprofen in case needed during the night and following morning, and educated ct on dosing instructions as well as possible side effects. RN suggested use of heating pad and/or massage for continued cramping and pain. Ct states she will alert RN if additional measures are needed. Ct appears well groomed, relaxed, well rested. Ct's affect appropriate, maintains good eye contact. Ct had phone session with Dr. Cowan today at 1800. Ct and fiancé went out to dinner. Ct left and returned in good spirits. Ct states that she has an appointment with Dr. Cowan on Monday, September 1. They will alternate phone and Skype sessions. Positive reinforcement given for ct's continued therapy sessions and for adherence to medication schedule.

Plt46 pg 03

2014-08-31

11:20 am

8/31/14

1120 - Patient text to say that he was having neck and shoulder pain. RN assessed patient and administered Toradol 60mg IM ROUQ and Baclofen 20mg. Patient encouraged to do some stretching exercises and get a massage today. Patient's fiancé stated that she would make an appt for him. Patient stated he took his routine AM medications around 1000. Report emailed to MD. Plan is for RN to check in with patient around 1800.

Plt41 pg 36/37

2014-08-31

09:00 pm

2100 - Patient and Fiancé went out for the afternoon shopping. Patient ate 50% lunch of a salad. This evening patient, fiancé and both RN's went to the Tate museum. Patient was in great spirits and was focused on the museum and stated he really enjoyed himself. Patient self-administered routine medications at 1500. Patient continues to complain of body aches but does not request medication at this time. Plan is for patient to get a massage this evening and go to sleep early as he has to work early tomorrow morning.

Plt41 pg 37

8/31/14
Ct notified RN at 0945 that she was awake and had self-administered Latuda 20mg and Provigil 200mg. RN will remind ct at appropriate times for Neurontin 100mg dosing today to assist in establishing pattern for ct. Ct appears in good spirits. States she slept from 0400 to 0800 but woke with energy. Ct states she is fatigued but believes interrupted sleep is related to jet lag. Mood calm, relaxed. Affect appropriate. C/o moderate menstrual cramping 5:10 and was given Motrin 800mg at 1230. Ct self-administered Neurontin 100mg at 1215 without prompting. Ct appears to tolerate Latuda well thus far. Ct denies SI, irritability, agitation. No signs or symptoms of NMS or TD noted. BP while sitting 92/50, pulse 64 and regular. Ct self-administered Neurontin 100mg at 1800 without prompting. Positive reinforcement given for establishing medication schedule. Ct given naproxen 250mg if needed for menstrual cramps as ibuprofen is not fully effective. Ct educated on medication and possible side effects. Ct ate 100% dinner and is adequately hydrated. Ct plans to use spa facilities and receive facial tonight to relax.

Plt46 pg 03/04

2014-09-01

06:30 am

9/1/14

0630 - Patient awake and self-administered routine AM medications at this time. Stated his body aches feel much better after his massage last night. Patient encouraged to drink plenty of water throughout the day today. Patient is alert and energetic and looking forward to his first day of work. Plan is for RN to visit patient on set this afternoon.

Plt41 pg 37

9/1/14
Ct woken by RN at 1215. States she took HS medication with addition of Ambien 5mg last night at 0100 and fell asleep at 0230. Ct slept soundly through the night. Ct mood, affect, eye contact appropriate. Ct denies TD or NMS symptoms. Manual BP left arm while sitting 88/60, pulse 78 and regular. Ct given Latuda 20mg and Provigil 200mg at 1230. Ct c/o menstrual cramps and was given ibuprofen 600mg at 1300 per her request. RN and ct have spent time together building rapport. Ct is opening up to RN regarding family history and relationships. Ct was informed via friend that some information on her cell phone may have been leaked due to hacking. Ct expressed concern but maintained stable and appropriate reaction. Positive support given for healthy coping skills. Ct appears happy, appetite good, able to hold attention for medication education. Ct is provided with pill boxes with appropriate medication for today and tomorrow. Ct expresses excitement regarding beginning online religious studies class tomorrow. Ct will have phone session with Dr. Cowan at 1700, then ct and RN will go to the spa together per ct's request.

Plt46 pg 04

2014-09-01

06:45 pm

1845 - RN went to set to check in with patient. He complained of body aches and stated his body was tightening up throughout the day. Torodol 60mg IM ROUQ given and Baclofen 20mg given at 1530. Patient stated he self administered in routine afternoon meds at 1230 and stated he was feeling lethargic. Adderall 5mg prn given at 1800. Patient will check in with RN upon arriving back at hotel this evening.

Plt41 pg 37/38

2014-09-01

07:00 pm

1900 Ct informed RN she self-administered Neurontin 100mg at 1345, Provigil 200mg at 1445. Ct reminded to take Neurontin 100mg at 1830 and she did so immediately.

Plt46 pg 04

2014-09-01

10:10 pm

2210 - Patient back at hotel. Planning on going to bed shortly as he is exhausted. No complaints at this time.

Plt41 pg 38

2014-09-01

11:50 pm

2350 RN and ct spent time in spa during evening. Ct's mood calm and stable despite dealing with phone hacking. Positive reinforcement given for healthy coping skills. Ct appears to have difficulty maintaining attention for continuous periods. Ct reports numbness x 20 minutes in both hands while receiving manicure and states same experience happened yesterday afternoon. RN to report to Dr. Kipper. Ct continues to build trusting relationship with RN. Ct self-administered HS medication at 2230 and retired to hotel room with fiancé.

Plt46 pg 04

Plt41 pg 38

2014-09-02

07:30 am

0730 - Patient had a hard time waking up this morning. RN noted that he did not take his HS medications last night but states he slept soundly. Patient stated he was exhausted and fell asleep and forgot to self-administer medications. Patient self-administered routine AM medications at 0645. Complained he was still experiencing body aches and had night sweats during the night. Toradol 60mg IM LUOQ and Baclfen 20mg prn given at 0725. Patient is off to work. RN will visit patient on set this afternoon.

Plt41 pg 38

2014-09-02

04:00 pm

1600 - Visited patient on set. States he is having some break through anxiety and is taking Xanax 1.5 mg prn for the past 3 days. Patient asked if Xanax .5 - 1mg could be added to routine morning medications. Patient educated on how Xanax is addictive and our goal is to have patient only use Xanax in emergency situations while we are increasing Lamictal throughout next couple of weeks. Will discuss options with MD. Patient stated was still experiencing body aches but did not require any prn medications. Plan is for patient to attend an awards ceremony tonight and will be picked up for work tomorrow at 0730. RN will visit patient on set again tomorrow. Patient given all routine medications to self administer for 9/3/14

Plt41 pg 38/39

2014-09-02

09:50 pm

2150 - Spoke to MD. New medication orders:

D/C Seroquel 25mg QAM
Start Seroquel 50mg QAM

Plt41 pg 39

9/2/14

Ct in good spirits during morning despite sleeping only from 0300 to 0730. Ct took Provigil 200mg at 0800, Latuda 20mg at 0945, Neurontin 100mg at 1100. Ct self-admin Ambien 5mg at 0100 last night but then started painting. RN educated ct on onset, duration, and proper administration of Ambien, and encouraged ct to only take Ambien when needed and to be in bed ready for sleep when she administers it. Ct ate small fruit breakfast. States "I feel really good." RN and ct discuss ct's history and current relationship. Ct reports difficulty with jealousy issues and anxiety around fiance's fame and ability to interact with females often. 1:1 emotional support given. Ct is encouraged to continue activities to enhance well-being such as therapy, journaling, sleep hygiene. Ct agrees. Ct requests RN to continue stay in London as it is assisting her mood stabilization and comfort. RN agrees to do so and reassures ct that she will have access to RN as long as needed.

Plt46 pg 05

9/2/14

Ct moved into new home in London. Mood cheerful and stable throughout day. RN notified Dr. Kipper of ct's insomnia. Orders received to increase HS Neurontin to 600mg and to be given two hours prior to bedtime. RN educated ct on medication change and also on necessity to use Ambien only as last resort. Ct verbalized understanding and expressed reassurance regarding Dr. Kipper's recommendation. Ct preparing for outing with fiancé and declines RN offer to remind her for Neurontin administration. Ct will notify RN of any needs.

Plt46 pg 06

2014-09-03

05:30 pm

9/3/14 - 1730 Visited patient on set from 1400 - 1700. Patient was in good spirits but complained of continually feel lethargic due to his long work days. Patient told RN that he took an additional Adderall 10mg yesterday. He took medication from today's med box. RN refilled today's med box and explained to patient that he could not increase his medications on his own. Per MD - B12 will be delivered tomorrow and this will help with patient's energy. RN will discuss other options with MD tonight. Patient complained of continued body aches and Toradol 60mg IM LOUQ administered with good effect. Patient given routine medications for 9/4/14. Plan is for patient to work till 2200 tonight. RN will come to set again tomorrow to assess patient.

New Med Order:
Adderall 10mg – 1/2 - 1 tab prn lethargy QD during work days

Plt41 pg 39

9/3/14

Ct awake at 12:30pm. States she slept well but is "groggy." RN informed ct that she will decrease HS Neurontin to 400mg tonight per Dr. Kipper. Ct has maintained focus and attention during online class x 2 days. RN changed ct's pill boxes to reflect medication change for HS. Ct in good spirits throughout day. Self-admin Neurontin 100mg at 1430 and 1855. Ct denies taking Ambien last night. Positive reinforcement given for following treatment advice. Ct hygiene good, appetite good. Ct maintains adequate oral fluid intake. Ct and RN spent time together today; rapport established. RN reminds ct to take Neurontin 400mg two hours prior to bedtime. Ct verbalizes understanding. Ct states she will notify RN of any needs during night and will contact RN upon wakening.

Plt46 pg 06

2014-09-04

12:30 pm

9/4/14 - 1230 - Per assistant, RN unable to go to set due to transportation. Per assistant, patient ok with seeing RN at home, after work.

Plt41 pg 39

2014-09-04

12:30 am

0030 - Patient home from work. Complained of body aches and muscle tension in neck 6/10 Toradol 60 mg IM LOUQ, baclofen 20mg administered with good effect. Explained to patient that MD would like patient to only take an extra dose of adderall during the work week and rest when needed on the weekends. MD would also like patient to try not to take any Xanax over the weekend to give his body a break from the benzos. Patient reminded that Xanax is for emergency anxiety of 8/10. Patient verbally agreed. VS 121/74 P92. Patient self-administered HS meds at this time and is going straight to bed. Patient requested to RN come to work with him tomorrow. Plan is to meet at house at 11:30am.

Plt41 pg 39/40

9/4/14

Ct awake at 0900. Reports sleeping soundly from 0300 to 0900. Woke without difficulty this morning. Denies lethargy, fatigue, or "grogginess." Dr. Kipper notified of dosage reduction effectiveness. RN confirmed with ct that she will continue Neurontin 400mg two hours prior to bedtime, as dose was effective. Ct spent day participating in online college course, attending a meeting, and studying. Ct self-administered all medications at proper times without prompting. Ct, RN out for shopping with ct's assistant and Debbie, RN this evening per ct's request. Ct ate dinner with RN at 2100 at restaurant. Ct became frustrated with wait staff over miscommunication; ct calmly repeated herself to staff to resolve issue. Ct expressed frustration after conflict to RN. RN reflected change in coping mechanisms as ct's previous coping skills involved impulsive anger and yelling. Ct able to acknowledge ability to process conflict and expressed pride in healthy conflict resolution. Ct had small piece fish and salad at home at 2330. RN discussed eating small, frequent meals throughout the day with ct as she tends to have limited amount of food during daytime and consumes most of her daily calories 1-3 hours prior to bedtime. Ct is social, affect and mood appropriate. States minimal anxiety. Ct expresses appreciation of RN's presence and assistance, and reports that she "is feeling great" with her current medication regimen. Positive reinforcement given. Manual BP 96/50 left arm while sitting, P 78. RN has created chart of VS for ct so she is able to determine baseline VS. Ct expresses much interest in well-being. Ct plans to fly to NY Sept 7-8 for work; declined RN's offer to accompany her. RN will ensure ct has all medication and instructions prior to departure.

Plt46 pg 06/07

2014-09-05

01:00 pm

9/5/14 - 1300 - Currently at set with patient. Stated he self-administered routine AM meds at 1100 along with a prn Xanax 0.5mg. Patient complains of mild neck / shoulder tension and pain. Patient shown some stretching exercises and practiced them with good effect. Patient encouraged to stretch every morning after his shower. Patient also encourage to get weekly massages to work out the tension in his shoulder and neck. Patient agreed to do so over the weekend.

Plt41 pg 40

2014-09-05

03:30 pm

1530 - Patient relaxing in trailer between shoots. B12 1cc administered ROUQ.

Plt41 pg 40

2014-09-05

09:40 pm

2140 - Patient back home from work. Fiancé expressed some concerns about his decreased appetite. Patient agreed he does not have an appetite but explained to fiancé that he is drinking protein shakes during the day. Patient agrees to work on some nutritional goals after the weekend. Patient plans on spending the weekend at home relaxing. He is given routine medications for 9/6 & 9/7 with instructions to call RN if needed at all during the weekend.

Plt41 pg 40

9/5/14

Ct awake at 0815. Administered Provigil 200mg and Latuda 20mg at 0820. Neurontin 100mg and Provigil 200mg self-admin at 1205 per ct. Positive reinforcement given for adhering to medication administration schedule. Ct attended work meeting and then request RN to go shopping. VS checked at 1400, BP 94/56 P 62. Ct appetite good. Ate 100% salad with falafel at lunch. Ct mood stable and appropriate. When asked how she feels about current medication regimen ct states, "it is working well for me, I feel great." Ct taking responsibility for self-admin medication at scheduled times. Ct reports fatigue today but does not nap. Tolerates 40 minutes light walking well. Ct ate 100 % dinner with RN. VS taken again at 2230 per ct request. BP 96/52, P 84. Ct reports that she was accepted for acting role in film to begin at undetermined date. Ct discussed concerns regarding fiancé's' weight loss in front of fiancé and both RNs, and implemented effective conflict resolution. Positive reinforcement given for healthy coping skills.

Plt46 pg 07

2014-09-06

09:25 pm

9/6/14 - 2125 - RN checked in with patient via text message and patient replied "all's well...Great day!!! Went to see play for about 11 minutes and split at intermission!!! Fucking dreadful!!! Now going to get a bite to eat... Definitely different with the Adderall!!! Struggled to stay awake during the play... More pleasant with, for sure. But, I'm up for the experiment!!!" Status reported to MD via telephone.

Plt41 pg 40/41

9/6/14

Ct awake at 1200, self-admin Latuda 20mg and Provigil 200mg. Ct states she will decline second dose of Provigil today to increase nighttime sleepiness. Ct reports sleeping soundly through the night. Ct and RN in touch via text throughout day. Ct spent day with fiancé and reports that she told fiancé about acting role and he was accepting of it. RN encouraged ct to notify her with any concerns and to notify RN upon waking tomorrow.

Plt46 pg 07

2014-09-07

04:00 pm

9/7/14 - 1600 – RN went to see patient in his home. He stated he has a nice weekend with his fiancé and he is pleased with how they are communicating and with how they are getting along. He states he continues to feel clearer every day and is thrilled with his creativity at work. He expressed gratitude for his "clarity" and is very happy to have the "blue mini beast" off his back. Patient given positive reinforcement for all the positive changes that he has made in his life over the past month. Patient states that he was not able to go the weekend without taking any Xanax. States he took Xanax 1mg before going out yesterday evening. Again, patient reminded to limit the Xanax for severe, breakthrough anxiety. Patient verbally agreed. B12 100mg 1cc administered ROUQ. Patient given rountine medications for 9/8/14. Plan is for patient to relax and play music for the evening and then get a massage at 2100. RN will go to set tomorrow at 1300 to check in with patient.

Plt41 pg 41

9/7/14

Ct states she slept from 0100 until 0630. C/o vivid dreams and nightmares. Ct appears anxious, withdrawn. States she felt increased agitation yesterday. Ct reports withdrawing and isolating when with fiancé yesterday, but able to recognize her behavior and communicate with fiancé. Positive reinforcement given for reflection and healthy coping skills. Ct is going to NY this morning by herself for work commitment and will return Tuesday Sept. 9. Ct reports anxiety related to travel, being alone, family issues, impending work. 1:1 emotional support provided. RN educated ct on effects of anxiety such as insomnia, vivid dreams, and agitation. RN taught ct deep breathing exercises and relaxation techniques. Ct provided with routine medications in addition to Inderal and Neurontin 100mg to take PRN for anxiety. RN will assist ct with anxiety via phone while ct is in NY, and will implement a physical exercise routine with ct upon return. Ct continues therapy sessions with Dr. Cowan every other day and states she is learning coping mechanisms and effective communication skills. RN notified Dr. Kipper of ct's increased anxiety.

Plt46 pg 07

2014-09-08

12:30 pm

9/8/14 - 1230 - RN received text from patient assistant that he is wrapped for the day and will be heading home soon. New plan is for RN to see patient at his home at 1500.

Plt41 pg 41

2014-09-08

01:00 pm

9/8/14

1300 Ct in NY for work. Reports sleeping from 0300 to 0745. Ct woke feeling anxious and questions RN if Latuda is causing insomnia. 1:1 emotional support given. RN educated ct on medication and provided reassurance. Ct is encouraged to continue therapy sessions with Dr. Cowan as she is experiencing several stressors currently. RN educated ct on effects of stress and anxiety on well-being and sleep patterns. Deep breathing and relaxation techniques reviewed with ct and implementation is encouraged. RN suggests creating plan with ct upon her return to have daily private time in which ct can discuss health and mental status, mood, sleep, questions, concerns, etc. with RN. Ct agrees to do so. Dr. Kipper updated on ct's increased anxiety and insomnia. Orders received to increase Neurontin to 100mg po tid and keep Neurontin 400mg po qhs. Ct educated on this change and is encouraged to begin immediately.

Plt46 pg 08

2014-09-08

08:30 pm

2030 - RN with patient from 1500 - 2010. Patient continues to be in good spirits and be motivated for "clarity". Patient stated that he was able to not take any Xanax yesterday. Complained of mild anxiety at 1630 and self-administered Inderal 40mg VS 127/77 p 80. Patient encouraged using the gym, pool and sauna in his home to work through some of his anxiety rather than reaching for medications. Patient agreed and went to turn on sauna for later use. Patient and RN set up a plan to work on his nutritional goals starting this week. RN went over goals with chef. Plan is for chef to pack small portions of protein and veggies and for patient to have small portions throughout the day. Patient agreed to try replacing some of the red bulls he drinks with coconut water throughout the day. Patient eating dinner of fries and a burger when RN leaves. Patient has the day off from work tomorrow and will text RN in the morning to set up a time to visit tomorrow.

Plt41 pg 41/42

2014-09-08

10:00 pm

2200 Ct had phone session with Dr. Cowan this afternoon. Has been busy with work commitments throughout day. RN encouraged increased oral fluids and small meals throughout day. Dr. Kipper discussed ct's status with RN. Orders received to increase Neurontin to 200mg po TID and Neurontin 400mg po qhs. Ct made aware of medication change and will begin increased dosages on 9/10/14 AM as she does not have medication with her currently.

Plt46 pg 08

2014-09-09

11:00 am

9/9/14

1100 Ct reports sleeping 2 hours due to late work schedule and early flight. RN encouraged ct to take Neurontin 100mg q4 hr today as she will travel from NY to London, and will experience a longer day. RN plans to meet with ct upon her return this evening to review new medication changes and assess mental and physical status.

Plt46 pg 08

2014-09-09

03:00 pm

9/9/14

1500 - Went to see client in his home. He stated that he slept well last night and self administered routine AM meds at 1030. Patient stated that he feels he is still experiencing anxiety throughout the day and would like to try other medication options. Status reported to MD - Inderal LA 80mg PRN QD ordered. Inderal administered at 1330 VS 117/74 p79. Patient continues to complain of body aches 5/10 Motrin 800 mg, Baclofen 20mg administered at 1400 with good effect. Plan is for patient to get a massage at 1700. Patient stated he ate 75% of his dinner last night and has been drinking coconut water throughout the day today.

New Med Orders:
D/C Lamictal 25mg QD
Start Lamictal 37.5mg QD x7D
Inderal LA 80mg QD PRN anxiety

Plt41 pg 42

2014-09-09

11:00 pm

2300 Ct returned this evening with friends and sister. Having dinner with fiancé. States she is fatigued but mood stable. RN will assess ct in the morning.

Plt46 pg 08

2014-09-10

01:00 pm

9/10/14

1300 - Per assistant, RN is unable to go to patient's work to see him due to transportation issues. Patient will be seen at his home when he is finished with work.

Plt41 pg 42

2014-09-10

04:00 pm

9/10/14

1600 Ct states she slept soundly from 0100 to 1130. Appears in good spirits, states she "feels so much better after sleeping." RN met ct and friends at house. Ct hygiene is good. Observed drinking adequate fluids. RN reviewed medication changes with ct. Ct is hesitant to take Neurontin 200mg TID as she fears sedation. Ct and RN agree for ct to take Neurontin 100mg TID and 400mg at HS and will reassess anxiety and medication effectiveness. RN and ct agree to have private session during afternoon to discuss ct's mental and physical status. Ct, RN, and ct's friends out on a walking tour for several hours during the afternoon. Ct takes medication as scheduled without prompting. Mood stable throughout day. Ct will have therapy session with Dr. Cowan at 1700.

Plt46 pg 08

2014-09-10

09:20 pm

2120 - RN received call from patient's assistant stating the patient was requesting an extra dose of Adderall and had asked assistant to take it from tomorrow's meds. Assistant instructed to tell patient that he cold not do that and reminded assistant that patient is not allowed to self medicate and change his medications without speaking to MD and situations like this are why RN needs to see patient while he is at work.

Plt41 pg 43

2014-09-10

10:15 pm

2215 - Received text from patient that he is on his way home, stating that "he feels a little weird. Trying to rule out possibilities.......... No biggie, though! Promise though. Might be lack of sleep, or a lack of food??? Patient informed RN would be at house to see him when he got home.

Plt41 pg 43

2014-09-10

11:30 pm

2330 - Met with patient. He complained of body aches and nausea. Phenergan 100ml IM RUOQ administered with good effect. Patient reminded the importance of eating small portions throughout the day. While RN was visiting patient, fiancé came in and tried to start at argument with him. Patient was able to stay calm and talk his fiancé down. Patient given positive reinforcement for his reaction. RN encourage patient to take his HS meds within the next 30 minutes and to get some rest. Patient was exhausted but in good spirits when RN left home. Plan is for RN to visit patient at work tomorrow.

Plt41 pg 43

2014-09-10

11:30 pm

2330 Ct experienced increased anxiety and appeared more agitated during evening hours. Ct took additional Neurontin 100mg at 2100 for anxiety. BP 115/68, P 88. RN reviewed deep breathing exercises. Ct returned demonstration. RN discussed ct's stressors including friends present, work commitments, relationship. Healthy coping mechanisms reviewed. Ct observed consuming several glasses wine. Affect flat, appears withdrawn. Ct expresses anger toward fiancé's friend and associates blame for fiancé's substance abuse. 1:1 emotional support given. RN attempted to process feelings with ct but ct declined. RN encouraged ct to notify RN of any needs throughout night.

Plt46 pg 09

2014-09-11

07:00 pm

9/11/14

1900 RN met ct at house at 1300. Ct states she slept from 0200 until 0830. Ct appears fatigued. Ct took vitals upon waking as she felt anxious. BP 85/67, P 121 while supine. Oral fluids encouraged to correct dehydration, Ct self-admin Latuda 20mg and Provigil 200mg at 1015, then Neurontin 100mg at 1230. Ct requests and is given Vit B12 1cc IM left ventrogluteal at 1315. Ct, RN, and friends spent several hours shopping and sightseeing. Ct c/o intermittent nausea and fatigue throughout day. Declines offer to return home to rest. Ct observed eating variety of foods. Provigil 200mg taken at 1400, Neurontin 100mg taken at 1500. Upon return to house at 1800, ct c/o nausea, fatigue, feeling "dizzy" while sitting. BP 99/72, P 70 at 1820. Ct encouraged to rest this evening. Zofran 8mg given at 1820. Ginger tea provided. Dr. Kipper notified of ct's status. Orders received to increase Latuda to 40mg po qam and change Neurontin to 200mg po bid and 400mg po qhs.

Plt46 pg 09

2014-09-11

10:10 pm

9/11/14

2210 - Spent the day with patient at work. His appetite has mildly increased. For breakfast he ate 2 hard-boiled eggs, for lunch he had 1/2 tuna sandwich and had a protein shake for late afternoon snack. Patient stated he self-administered routine AM meds at 1100 and routine afternoon meds at 1710. At 1500 patient complained of neck and shoulder pain 7/10 - Baclofen 20mg, Motrin 800 mg administered. AT 1720 - Patient continued to complain of neck and shoulder pain 6/10 - Toradol 60mg IM LOUQ administered with good effect as pain decreased to 2/10. Plan is for MD to arrive tomorrow morning and MD and RN will visit patient at work. Patient given all routine meds for 9/12/14 for self - administration.

Plt41 pg 43/44

2014-09-11

11:50 pm

2350 RN assessed ct throughout evening. States nausea minimal but continues to c/o fatigue. RN and ct had 1:1 discussion about ct's increased anxiety, agitation, insomnia, and life stressors. Ct receptive to support and expressed fear r/t fiance's possible relapse. RN encouraged ct to stay present and highlighted need to focus on ct's own well-being. Relaxation and distraction techniques reviewed. Ct expresses hesitation r/t increase in Latuda dose and change in Neurontin. RN provided medication education and explained how medication and cognitive/behavioral techniques are used to increase well-being. Ct verbalizes understanding and agrees to medication regimen. Positive support given for adhearance to medication regimen and for expressing feelings, concerns, questions to RN. Ct will continue with psychotherapy every other day and is utilizing learned coping skills to minimize anxiety.

Plt46 pg 09

2014-09-12

11:00 am

9/12/14

1100 Ct notified RN of c/o drowsiness at 1015. States she took Provigil 200mg, Latuda 40mg at 0900 and Neurontin 100mg at 1015. Ct declines to take full dose of Neurontin d/t fatigue and drowsiness. RN encourages ct to take ordered dose of Neurontin within 1 hour. Ct is currently spending time with friends and will notify RN when she is available for assessment. Ct plans to have therapy session this afternoon and then go to France for the weekend with fiancé.

Plt46 pg 09

2014-09-12

05:00 pm

9/12/14 - 1700 - RN and MD visited patient at work. Patient continues to be satisfied with his "clarity" progress and expresses appreciated for medical team. Patient expressed some concerns with fiancé's behavior and how it is adding stress to his life. Patient given positive reinforcement on how he is working through his emotions and redirected to continuing to work on himself as his fiancé is continuing to work with her treatment team. MD gave patient some communication techniques to use with his fiancé when confrontation situations arise. MD also suggested it was time for patient to begin working with a psychiatrists and patient agreed. Patient informed MD and RN that he will be traveling to France with his fiancé this weekend. MD and patient decided it would best for patient and fiancé to travel without treatment team so they could be alone and focus on one another for the weekend. RN gave patient all routine medications for 9/14, 9/14, 9/15 for self-administration. Per MD orders patient was given Xanax 1mg #5 and Adderall 10mg #5 as prn medications for his trip. Plan is for RN to check in with patient via text msgs throughout the weekend and will see him back at work on Monday.

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2014-09-12

08:00 pm

2000 RN assessed ct throughout day. Ct continues to c/o fatigue. Hydrating adequately. Ct met with Dr. Kipper. Ct expressed gratitude to RN for 1:1 talk the night before. States she was able to process anger, fear, and anxiety in order to have therapeutic communication with fiancé. Positive reinforcement given for insight, processing, and utilizing healthy coping and communication skills. Ct asks RN for reminders of medication administration times as she feels more confident in utilizing medication to achieve mood stabilization. RN will do so. Ct left house with sister at 1945 and will be in France for the weekend with fiancé. All medication provided to ct upon departure.

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2014-09-13

08:10 pm

9/13/14 - 2010 - RN checked in with patient via text msg. Patient returned text and stated he was doing well and was "sort of" catching up on sleep.

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9/13/14

Ct states she slept soundly last night x 10 hours. RN has reminded ct at medication administration times. Ct medication compliant today. RN has encouraged ct to notify of any questions or needs.

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9/14/14 - Did not hear from patient today. Per his sister he is doing well and will return to London late tonight.

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9/14/14

Ct remained in France most of day. Returned to house in London late tonight. Self-admin Latuda 40mg and Provigil 200mg at 1100, Neurontin 200mg at 1300, Neurontin 200mg at 1825, and Neurontin 400mg at 2315, Ct then self-admin melatonin 20mg at 0015. RN plans to meet with ct tomorrow. Ct has had limited interaction and communication with RN throughout weekend.

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2014-09-15

07:00 pm

9/15/14 – 1900 – RN and MD went to visit patient at his work. Patient stated he had a nice weekend and that things were peaceful between him and his fiancé. Patient spoke about really enjoying being at his house in France for the first time in three years and being able to enjoy it with a clear mind. Patient continues to complain of neck pain and waking in the mornings with a headache. MD feels this is from tendinitis in the neck and will order cortisone IM to be delivered on 9/17/14. Patient given all routine medications for 9/16/17 for self-administration. Plan is for RN and MD to see patient tomorrow at his home as he had the day off from work.

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9/15/14

Ct had several appointments and meetings today; did not see RN. Ct continued therapy with Dr. Cowan this afternoon. States she had a relaxing weekend and "feels good besides the morning grogginess." Dr. Kipper notified and will meet with ct tomorrow to discuss fatigue and medication regimen. RN will assess ct tomorrow and encourages ct to notify of any needs throughout night.

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2014-09-16

01:00 pm

9/16/14 - 1300 - MD met with patient briefly this morning. RN did not see patient but left his routine medications for 9/16/14 with his fiancé to give to patient for self-administration. Plan is for patient to spend day relaxing and playing music with a friend. RN and MD will see patient at 11 am tomorrow.

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