DATE OF ADMISSION: ___ [DATE].
DATE OF DISCHARGE: ___ [DATE].
FINAL DIAGNOSES
AXIS I: Schizophrenia, undifferentiated type, acute relapse, alcohol abuse, marijuana abuse, noncompliance with the medical treatment.
AXIS II: None.
AXIS III: Obesity, non-insulin-dependent diabetes mellitus, hypertension.
The patient is a 45-year-old male who was admitted because of withdrawal from all social interactions, and mild catatonic symptoms. He did not want to communicate with his family members. He was nearly mute, but when I talked to him, after about 5 minutes, he started to talk and answer questions to some extent. He agreed to the need of inpatient stay. The patient has been living with his mother and sister. He said that they are harsh on him, and so he decided to withdraw from everything, and stop communicating with them. The mother did not want him to
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TSH was 0.9, cholesterol was 256 and triglycerides at 280. Blood glucose was 262 on admission. Alkaline phosphatase 170. White cell count was 11,100, and his hemoglobin 12.2. Urinalysis was negative. EKG showed normal sinus rhythm.
HOSPITAL COURSE: The patient was placed on Seroquel, and the dose was increased to 900 mg per day. He was also placed on Ativan 0.5 mg t.i.d. He started communicating after about 2 to 3 days. His self (___) slowly improved. He is still hearing voices, but now the voices are more positive. Now, the voices are telling him not to hate his mother. Only 2 days ago, the voices were telling not to talk to his mother. His mood is fairly stable. He is much more functional now.
He is discharged as improved on the following medications:
1. Seroquel 300 mg 2 h.s.
2. Ativan 1 mg b.i.d.
3. He is also to continue on (Vasotec) 5 mg daily.
4. Glucotrol XL 15 mg daily.
Follow up in the office on a weekly basis for group psychotherapy, and medication management. No restrictions on activities. He is to stay on an ADA
Vital signs: BP 138/88; HR 88 (regular), RR 18, T 98.8 height 5’7”, weight 175 pounds BMI 27.4
His vital signs are as follows: BP 172/100, heart rate 92 beats per minute, and a temperature of 102.2 F. There have been some labs done. His red blood count is 3.1 million cells, white blood count is 22,000 cells, potassium is 5.4 mEq/L, calcium is 6.8 mg/dL, phosphate is 4.3 mEq/L, urea is 37 mg/dL, creatinine 2.0 mg/dL, albumin is 2.9 mg/dL, and pH is 7.29. With labs like these, more testing was done. A chemistry panel which showed protein 1.7
D-The patient requested an increase on her dose as she reports that she is experiencing chills. When asked as to what alternatives has done to address the chills rather than using illicit drugs. The patient reports she's been taking each day at time and used relaxation techniques; however, at times the "chills" can be unbearable to the point the patient does not want to relapse because she's been drug free for over a year, at which this writer provided positive feedback for the patient recovery process. Furthermore, this writer and the patient discussed the suspension of the patient take home bottles as the patient reports that the reason why the bottles were suspended was due to her medication; however, the patient reports she provided the clinic with an updated letter from her psychiatrist and notification that she is no longer prescribed with Hydroxyzone and wants to apply for all of her take homes. This writer addressed with the patient about program policy about medication/take home bottles. Furthermore, two of the patient's medication needs an updated RX script before the patient request can be reviewed. Also, a letter from her psychiatrist once again about the patient compliance with treatment and medication management. The patient reports she can get the updated script by next as this writer will assist obtaining an updated letter from her psychiatrist about the patient's overall treatment. This writer completed the dose change request form to increase the patient's dose by 5mgs.
Cano, the patient is status post right carnal tunnel release. She has been on physical therapy for the last three weeks. She states she is doing much, much better. Her left hand will be operated on 5/03/16. She complains of severe insomnia. This has been chronic with headaches and chronic depression. She states she is hearing voices, hearing auditory hallucinations with paranoia. This started after the oral steroids. She is psychotic and severely depressed. There is a past history of post-traumatic stress disorder (PTSD), generalized anxiety, and chronic depression. Previous antidepressants included Celexa, BuSpar and Xanax. She states she has been clean. There is no evidence of any type of drugs in her. She brought what she had and had thrown those out and had detoxed a few months
----- Clinic presents a black male 68 years old. Currently experiencing dyspnea and lethargy. For the past week he has been having a increase of difficulty breathing. Complains of alternating periods of sweating and chills. Other symptoms he has been experiencing is a productive cough with expectoration of thick yellow sputum. Patient is a ex- smoker, he was a 40 pack year history, denies smoking, stopped over 10 years ago. Medical history includes chronic bronchitis, hypertension, MI five years ago, has had a angioplasty, and denies chest pain since having angioplasty. Current medication combined albuterol/ipratropium MDI, nebulized albuterol prn, captopril, and hydrochlorothiazide.
During the time of assessment the patient presents drowsy. The patient reports during the time of assessment that he is not currently suicidal or homicidal. The patient reports that he hears voices telling him to kill him self and kill his wife. However, the patient reports that he loves his wife and do not wish to harm her. The patient reports that tonight that him and his wife got into an argument, however
During the time of the assessment the patient was found sleep. The patient was awakened by nursing staff for mental health evaluation. The patient appeared drowsy, however reports he is alert and will to forgo with the assessment. The patient states, "I don't know what my situation is." The patient reports recently having relationship issues with his girlfriend. The patient reports that he was unable to fill his 10 days worth of prescriptions due to the holidays.
Objective: Vital signs Temputure-97.2, Pulse-77, resperatin-22, Blood Pressure 165/81, Oxygen Saturation on room air is 91%, Weight-156lbs, and Height 5fl 8in.
1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.
Paranoid Schizophrenia can come on quick suddenly and disrupt a person’s normal daily functions. People suffering from paranoid schizophrenia prominently experience delusions and hallucinations. Some individuals can be predisposed to schizophrenia due to cortical atrophy hypothesis or the dopamine hypothesis. Cortical atrophy hypothesis believes that the patient’s brain size can cause schizophrenia, while the dopamine hypothesis argues that levels of dopamine in the brain are directly related to the onset of schizophrenia.
Dr. Haviland requested a status check to determine need for IVC and inpatient hospitalization. Patient presents today with appropriate appearance, minimal eye contact, slurred speech, appropriate affect, minimal anxiety, coherent/relevant thoughts, fair judgment, fair impulse control, good insight, oriented x4, normal concentration, no changes in sleep, and a good appetite. Patient denies current suicidal ideation with a plan. Patient engaged in crisis planning. The patient grandmother, Mrs. Miller, was contacted for collateral information. Mrs. Miller reports last night she called the police due to her grandson becoming angry and throwing things in the home. She states, " He almost hit me with a telephone." She reports he has a history of
CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.
The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.
Keefe (2011) describe case as a safe way for nurses to utilize theoretically and real knowledge to an actual or possible scenario. Case study also examines the in-dept of a nursing situation and apply decision-making skills as well as critical thinking to analyze the situation, and develop a cognitive reasoning abilities without harming a patient. According to Billing and Halstead (2012) case study is beneficial in that it stimulate critical thinking, retention, and recall. Case study also aid students in recalling pertinent information by associating the practical with theoretical. Developing a case study may be difficult and time consuming and may be deemed as disadvantages for faculty. Students may also desire the more traditional lectures
A professional nurse should be an advocate for the patient and their family. Recently, I was an advocate for a patient who wanted to stop his dialysis treatments after six years of treatment. He was not depressed or terminal but was a healthy ninety-year-old man. He admitted he “lived a good life, was at peace with God and was ready to go. He met with his family over Christmas and they encouraged him to reconsider his decision. The children encouraged to him to continue dialysis until January. He agreed, but set a date of January 18 to discontinue treatment. The daughter called several times and I reassured her that this was a thought out decision and he had spoken to his nephrologist several times about it. He also had conversed with