Jason chart information

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Mental Status:
  • Jason arrived at the clinic, on time, for his scheduled appointment today.  He has showered today and is wearing clean clothes, but has not brushed his hair.  On our initial interaction, I noticed that Jason had significant halitosis, had not brushed his teeth (thick yellowish coating on his teeth) and he complained of dry mouth. There was minimal eye contact, his gait was unremarkable, and his posture was moderately slumped over, which is consistent with his presentation when seen at previous clinic appointments as during home visits.

Jason’s affect is blunted, with minimal expression throughout the interview and reported his mood as 6/10 (10=best mood).  Both are consistent with his normal presentation and accurately reflect his diagnosis. Jason speaks in a quiet tone of voice.  He answers questions with brief phrases and generally elaborates when asked.

When responding Jason requires a couple of minutes to formulate his thoughts, but no other hesitation is noted. His speech is moderately slow, but his thoughts are well connected and his vocabulary accurately conveys his ideas (“Sometimes it is still hard for me to talk to other people. I’m not sure what to say.”)

Jason stated that being able to volunteer at the food back makes him feel “useful” and his speech became more fluid as he described some of his responsibilities for sorting the dry goods that were donated.  When asked about connecting with other volunteers Jason began fidgeting with his watch and stated “I try not to talk to anyone.”  

Jason stated that talking with other people is “still difficult”, and “I don’t like it much.”  Jason admitted to smoking crack cocaine twice last week (reports he usually only smokes once per week) because it was “easier to say something if someone talked to me.” Jason denied having delusions or hallucinations regardless of whether or not he was using crack.  However, he stated that after the high from smoking crack wore off he would often spend a couple of days secluded in his apartment.  

Jason also reported feeling more anxious during this time, and “a little depressed”, and that “I stay in my apartment until it goes away.” Jason was able to follow the conversation without being distracted, and acknowledges his schizophrenia has been well managed with medications and a structured day. At this time Jason does not believe his drug use is a problem, despite having used crack more often since he started volunteering at the food bank.

Risk Assessment:
  • Jason denied suicidal and homicidal ideation, as well as thoughts of self-harm. Jason remarked that he thinks his life is going well, and wouldn’t hurt himself or anyone else because “That would hurt my parents.  They love me.” This is consistent with Jason’s health status over the past year.
  • Receives AISH as his sole income.
  • Jason continues to live in subsidised housing.
  • Meets every other day with a small group of friends, who also live in the apartment complex, and states that they mostly hangout and drink coffee, talk, and once a week “we get high together”.
  • Two weeks ago began volunteering at the food bank and states this helps him feel “useful”, but that is remains difficult to talk with people outside of his small group of friends.
  • Jason acknowledges that his parents care about him.
Diagnostic Tests
  • Jason is slightly obese

o   Height 5’ 8”

o   Weight 260 pounds

  • Last blood work done 2 weeks ago and is NORMAL

o   Next blood work in two weeks

  • Risperdal Consta 375mg IM every two weeks
  • Multivitamin
  • Currently on a community treatment order (CTO)

o   To be reviewed in 8 months