This is a transfer summary on O.G as patient will be leaving the hospital today and will be transitioned to his own physician
This is a transfer summary on O.G as patient will be leaving the hospital today and will be transitioned to his own physician
Respond to two peers with the following: Read another student’s progress note and assume that you are a PMHNP who will see this patient in an outpatient practice for follow up. Is there anything that wasn’t clear in the note that you would like to ask your NP colleague? Also, assume the patient isn’t tolerating the medication when you see them in follow up. Identify an alternative medication that would be appropriate and why you would choose it.
Post 1-
REASON FOR TRANSFER SUMMARY: This is a transfer summary on O.G as patient will be leaving the hospital today and will be transitioned to his own physician.
DATE OF ADMISSION: 03/23/2023
DATE OF DISCHARGE: 03/28/2023
DISCHARGE DIAGNOSES: Major depression, recurrent, with psychotic features.
REASON FOR ADMISSION: The patient was admitted with a chief complaint of severe depressive and psychotic episodes. The patient was brought to the hospital after she said to her husband she do not want to continue living, and and she was irritable, anxious and depressed moods, tearful at times, homesick, she do not want to eat and do not interact with family and friends, She stated, “strange feelings and sensations” and she was hearing voices and she tell her husband that she saw a person walking around all the time , She think peers , family wants to hurt she. She do not want her parents be near her.
PSYCHIATRIC HISTORY:: Major depression, recurrent, with psychotic features.
Last hospitalization was in 2020 due to suicide attempts.
PROCEDURES AND TREATMENT: Individual and group psychotherapy. Individual Cognitive Behavior Therapy. Family therapy.
Psychopharmacologic management. Seroquel 25 mg p.o. a.m. #30 pills no refills; Seroquel 50 mg p.o. q.h.s; Benadryl 50 mg p.o. q. 6h p.r.n. for anxiety or agitation #30 pills; Wellbutrin XL 300 mg p.o. q.a.m.; vitamin E 400 IU p.o. q.d. #30 pills; Restoril 25 mg p.o. p.r.n. for anxiety #16 pills.
3. Family therapy is conducted by social work department with the patient and the patient’s family for the purpose of education and discharge planning.
HOSPITAL COURSE The patient was in the hospital from 03/23/23 until 03/28/23. The most prominent symptoms and behaviors while the patient was here were the following: Perceptual disturbances, disorganized thoughts, she was suspicious at times, at some point she was complaining of audiovisual hallucinations. She was quiet showing a flat affect, irritable, anxious and depressed moods, tearful at times, homesick, limited interaction with peers. She was attending groups, however, was showing limited participation. She was superficial, not really working too much on her issues, more focused on how soon she was going to be discharged more than working on her issues. The patient has shown some improvement in general. However, she is not completely stable yet, and she sometimes is of relapse. She is probably just waiting for the discharge to the next level of care, which is the RTC program. However, the patient’s family will not follow our recommendations in this respect at this point.
DISCHARGE ASSESSMENT: At the time of discharge, The patient is alert, oriented to time, place, person, and situation. She denies suicidal or homicidal ideas at present exploration. She denies perception disturbances. She does not seem to be responding to internal stimuli at this point. She verbally contracted for safety.
ASSETS and LIABILITIES: Born and raised in Miami, with both parents, no siblings, married at 26, currently resides with her husband, she has been relative stable until 1 months ago
SHORT TERM GOALS and LONG-TERM GOALS: Patient will participate in Individual and CBT therapy, alternating with Family therapy The patient should visit her family doctor, cardiologist, and OB/GYN doctor for regular annual checkups. She should visit all these doctors regarding her lab results and/or her physical (medical conditions). continue treatment at hospital and outpatient.
DISCHARGE PLAN: The patient will be discharged per the family’s request. She will continue treatment at hospital and outpatient. The intake appointment will be on 04/10/2023 at 2:00 p.m.
The patient will continue on the following medications; Seroquel 25 mg p.o. a.m. #30 pills no refills; Seroquel 50 mg p.o. q.h.s; Benadryl 50 mg p.o. q. 6h p.r.n. for anxiety or agitation #30 pills; Wellbutrin XL 300 mg p.o. q.a.m.; vitamin E 400 IU p.o. q.d. #30 pills; Restoril 25 mg p.o. p.r.n. for anxiety #16 pills. The patient will follow up with Dr. B for medication management and Dr. G for psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work. Any other treatment recommendations
Thank you for receiving this summary.
Signature: Nancy Romero PMHNP student
Post 2
REASON FOR TRANSFER SUMMARY: This is a transfer summary on JY, as patient will be leaving inpatient services at Loma Linda Behavioral Health, and will be transitioned to Inland Empire Behavioral Group
DATE OF ADMISSION: 02/10/2023
DATE OF DISCHARGE: 02/25/2023
DISCHARGE DIAGNOSES: F30.1 Bipolar effective disorder with current episode manic without psychotic symptoms.
REASON FOR ADMISSION: JY, a 24-year-old male patient, was admitted with a chief complaint of feeling activated, yelling, and screaming at his parents during an argument. The patient was brought to the hospital after his parents called 911 because of his manic behavior. Parents reported patient was spending a lot of money for a week, not sleeping, or eating. His mood was eccentric, and he was planning to invest money in a business he does not know anything about. Patient got into an argument with his parents over the investment. Mother reported that JY became very angry, started screaming, and was uncontrollable. He was screaming on the street and the neighbors came out. The mother called 911. The patient was on a 5150 hold at Loma Linda Hospital, to 5250 at Loma Linda Behavioral Health.
PSYCHIATRIC HISTORY: JY reported that he was unaware he has bipolar. He stated his childhood was very normal, both of his parents raised him as a child. He recalls his mother does have a psychiatric illness, but he does not know what it is.
PROCEDURES AND TREATMENT:
- Individual and group psychotherapy: not necessary currently
- Psychopharmacologic management: Patient started on a mood stabilizer: Lithium 300mg two times a day.
- Family therapy for the patient and his parents recommended by the psychiatrist upon discharge.
HOSPITAL COURSE: This was the first time JY was hospitalized for a manic episode. Other than the manic episode JY stated that he is a very easy going, and compliant individual. He took his medications on time, and followed instructions given by the nurses and physicians. The psychologist conducted a family therapy session which JY believes helped him communicate with his parents in a healthy, and safe environment. The psychologist helped facilitate a discussion they would not have on their own.
DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully oriented. Mood is stable. Affect is congruent with thought process. Patient denies suicidal and homicidal thoughts, ideations, and plans. IQ is at baseline. Past and present memory intact.
ASSETS and LIABILITIES:Patient is aware of his current diagnosis. He understands the importance of continuing the medical regimen. JY stated he will look for a job when he is discharged and continue outpatient treatment for his psychiatric diagnosis. Patient’s support system consists of his girlfriend and his parents, whom he is very grateful for.
SHORT TERM GOALS and LONG-TERM GOALS: Patient’s short-term goal is to take his medications as directed, continue blood testing as needed, and continue a healthy diet and exercise regimen. Patient’s long-term goal is to get a job in construction and continue his education.
DISCHARGE PLAN: The patient was discharged after 15 days of inpatient care because he was not a risk of harm towards himself or others. The patient will continue Lithium 300mg BID. The patient will have his Lithium levels checked weekly, until he has reached a therapeutic level. The patient will follow up with Dr. Smith as an outpatient for medication management and Mr. Yung for psychotherapy.
Thank you for receiving this summary.
Signature: MR, PMHNP student
Requirements: minimum 100 words per post
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