County General Hospital 546 That Street Some Town, YY DISCHARGE SUMMARY

Transcription

1 County General Hospital 546 That Street Some Town, YY DISCHARGE SUMMARY PATIENT: Michael F. Byrnes UNIT#: ADMISSION DATE: June 5, 2006 ACCT#: DISCHARGE DATE: June 6, 2006 DOB: 05/19/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 345-B Issac Johnson, DSA dictating for Dr. Samantha Jackson DISCHARGE DIAGNOSES: 1. Post-Traumatic Stress Disorder. 2. Gastrointestinal pain, resolved. HISTORY OF PRESENT ILLNESS: This is a 28-year-old African American male with a recent history of anxiety and paranoia. He was recently discharged from the Army after two tours in Iraq. He is currently homeless and was yelling at anyone who came near him in the park. When approached by police he lashed out and they brought him to the hospital. He was hyper vigilant about his surroundings and had an exaggerated startle response when anyone entered his hospital room. He was very anxious about all of the monitors around him. The patient also complained of intense abdominal pain, likely related to ingesting rotten food. He was admitted for further evaluation and management. ALLERGIES: No known drug allergies. HOSPITAL COURSE: His blood work was within normal limits. Abdominal pain responded to antacids and acetaminophen. On the morning of June 6, the patient had calmed down in response to the paroxetine 20 mg administered the night before. He denied AH/VH. He denied any suicidal or homicidal ideations. He was prescribed paroxetine 20 mg, once daily. Dr. Jackson noted that he would need to follow up with social services and the Veterans Affairs Medical Center for ongoing treatment. CONDITION AT DISCHARGE: The patient was wanting to be discharged. He was alert and oriented x3. Vital signs were stable. His last recorded blood pressure was 107/61, heart rate 75. Lungs were PT: Byrnes, Michael F. UNIT: ACCT:

2 clear. Abdomen was soft, nontender, nondistended with positive bowel sounds. He was discharged on June 6, 2006, with discharge instructions given and medications reconciled. LABORATORY DATA: On June 5, sodium 143, potassium 3.8, chloride 109, co2 of 28, anion gap 6.0, glucose 122, BUN 17, creatinine 1.1, total protein 6.5, albumin 3.4, globulin 3.1, calcium 8.8, phosphorus 3.7, total bilirubin 0.3, AST 14, ALT 15, alkaline phosphatase 88, magnesium 2.2, triglycerides 50, cholesterol 150, HDL cholesterol 45, and LDL 120. Hematology values on June 6, white blood count 11.6, hemoglobin and hematocrit 12.3 and 36.5 respectively, with platelet count of 282,000. DISCHARGE MEDICATIONS: 1. Paroxetine 20mg, daily. 2. Calcium Carbonate, as needed. DISCHARGE INSTRUCTIONS: Follow up with Social Services as instructed r.e. housing. Follow-up with Veterans Affairs Medical Center for ongoing treatment. Dictated by Issac Johnson DSA DD: 06/08/ :25:34 DT: 06/08/ :15:25 CGHANYHSC; Job# Authenticated by Samantha Jackson MD on 06/12/ :45:21 PM PT: Byrnes, Michael F. UNIT: ACCT:

3 County General Hospital 546 That Street Some Town, YY HISTORY AND PHYSICAL REPORT PATIENT: Michael F. Byrnes UNIT#: ADMISSION DATE: June 5, 2006 ACCT#: ADMITTING PHYSICIAN: Jackson, Samantha DOB: 05/19/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 345-B DICTATING PHYSICIAN: Jackson, Samantha CHIEF COMPLAINT: The patient came in with extreme anxiety and agitation. The patient also complained of intense abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 28-year-old African American male with a recent history of anxiety and paranoia. He was recently discharged from the Army after two tours in Iraq. He is currently homeless and was yelling at anyone who came near him in the park. When approached by police he lashed out and they brought him to the hospital. He was hyper vigilant about his surroundings and had an exaggerated startle response when anyone entered his hospital room. He was very anxious about all of the monitors around him. The patient also complained of intense abdominal pain, likely related to ingesting rotten food. PAST MEDICAL HISTORY: None known. SOCIAL HISTORY: He is single, does not have any children, is currently unemployed and homeless. Does not smoke, denies drinking or using drugs but smelled of alcohol at admittance. FAMILY HISTORY: MEDICATIONS: REVIEW OF SYSTEMS: All other systems are reviewed, otherwise negative. ALLERGIES: PT: Byrnes, Michael F. UNIT: ACCT:

4 PHYSICAL EXAMINATION: GENERAL: The patient is lying in the bed, fidgeting often. Occasionally grimaces and holds his abdomen. VITAL SIGNS: Significant for patient s temperature of 99.2, pulse of 88, respiratory rate of 18, blood pressure of 107/61, and pulse ox of 97%. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular muscles are intact. No icterus, no pallor noted. NECK: Supple, no jugular venous distention, no thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, s!, s2 heard. No mumurs, gallops, or rubs. CHEST: Clear to auscultation. Abdomen: Soft, tender to the touch, nondistended. EXTREMETIES: No edema, No cyanosis. NUEROLOGIC: Alert and oriented x3 and follows all commands. LABORATORY DATA: The patient s CBC was within normal limits. The patient s CMP was also within normal limits. ASSESSMENT AND PLAN: Abdominal pain. The patient will be given calcium carbonate and acetaminophen. Anxiety and agitation. The patient will be given paroxetine 20 mg to stabilize. The patient will get social worker involved for further plan of care. We will start the patient on antianxiety medications. If this history and physical was performed prior to admission, but within the last 30 days, indicate by initialing one of the following: I have reassessed the patient and notes that there are no significant changes to the assessment. I have reassessed the patient and note the following significant changes occurred: DD: 06/05/ :25:30 DT: 06/05/ :14:09 CGHANYHSC; Job# Authenticated by Samantha Jackson MD on 06/07/ :49:45 AM Samantha Jackson Report ID: Electronically Signed by Samantha Jackson on 06/07/2006 at 0932 PT: Byrnes, Michael F. UNIT: ACCT:

5 County General Hospital 546 That Street Some Town, YY DISCHARGE SUMMARY PATIENT: Michael F. Byrnes UNIT#: ADMISSION DATE: August 12, 2007 ACCT#: DISCHARGE DATE: August 15, 2007 DOB: 05/19/78 ATTENDING PHYSICIAN: Freeman, Richard ROOM/BED: E. 256-A Issac Johnson, DSA dictating for Dr. Richard Freeman DISCHARGE DIAGNOSES: 1. Bipolar Disorder HISTORY OF PRESENT ILLNESS: This is a 29-year-old African American male with a recent history of mania and paranoia. He is currently homeless and was picked up by a crisis response team who found him under a bridge talking rapidly to himself and shaking uncontrollably. He had delusional ideas about how the government was listening to him and sending him messages. He appeared malnourished. He was admitted for further evaluation and stabilization. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to Unit E, placed on close observation and given a high-calorie diet. Throughout his hospital course he was placed on Lithobid and Zyprexa, and was given Benadryl prn for anxiety or agitation. Upon being admitted to the unit he denied auditory and visual hallucinations as well as suicidal and homicidal ideation. With a flat affect he was able to talk about his living conditions under the bridge. He stated that he preferred to be alone and did not have any energy to do things he used to do. He said that he hadn t been eating because he wasn t hungry. He most recently experienced a manic episode prior to his admission. On 08/14/2007 he was calm and cooperative. He reported no complaints. His mood had stabilized. Therefore, on 08/15/07 he was prepared for discharge. He is to receive aftercare at XYC Community Mental Health Center. CONDITION AT DISCHARGE: The patient was wanting to be discharged. He was alert and oriented x3. Vital signs were stable. He was discharged on August 15, 2007, with discharge instructions given and medications reconciled.

6 DISCHARGE MEDICATIONS: 1. Lithobid 300 mg 2 tablets PO bid 2. Zyprexa 5 mg 1 PO q hs 3. Benadryl 25 mg 1 PO bid DISCHARGE INSTRUCTIONS: Follow up with Social Services as instructed r.e. housing. Follow-up with Community Mental Health Center for ongoing treatment. Dictated by Issac Johnson DSA DD: 08/17/ :15:44 DT: 08/17/ :17:13 CGHANYHSC; Job# Authenticated by Richard Freeman MD on 08/19/ :53:23 PM

7 County General Hospital 546 That Street Some Town, YY HISTORY AND PHYSICAL REPORT PATIENT: Michael F. Byrnes UNIT#: ADMISSION DATE: August 12, 2007 ACCT#: ADMITTING PHYSICIAN: Freeman, Richard DOB: 05/19/78 ATTENDING PHYSICIAN: Freeman, Richard ROOM/BED: E. 256-A DICTATING PHYSICIAN: Freeman, Richard CHIEF COMPLAINT: The patient came in with symptoms of mania and paranoia. HISTORY OF PRESENT ILLNESS: This is a 29-year-old African American male with a recent history of mania and paranoia. He is currently homeless and was picked up by a crisis response team who found him under a bridge talking rapidly to himself and shaking uncontrollably. He had delusional ideas about how the government was listening to him and sending him messages. He appeared malnourished. He was admitted for further evaluation and stabilization. PAST MEDICAL HISTORY: Previous admittance to the emergency room June 5, 2006 with a diagnosis of Post- Traumatic Stress Disorder. SOCIAL HISTORY: He is single, does not have any children, is currently unemployed and homeless. Does not smoke. Admits to occasional heroin use. FAMILY HISTORY: MEDICATIONS: REVIEW OF SYSTEMS: All other systems are reviewed, otherwise negative. ALLERGIES: PHYSICAL EXAMINATION:

8 GENERAL: The patient is lying in the bed, talking to himself rapidly under his breath, glancing from side to side. VITAL SIGNS: Temperature of 98.3, pulse of 85, respiratory rate of 19, blood pressure of 110/60, and pulse ox of 98%. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular muscles are intact. No icterus, no pallor noted. NECK: Supple, no jugular venous distention, no thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, s1, s2 heard. No murmurs, gallops, or rubs. CHEST: Clear to auscultation. Abdomen: Soft, nontender, nondistended. EXTREMETIES: No edema, No cyanosis. NUEROLOGIC: Oriented to self and place, but not time. LABORATORY DATA: The patient s CBC was within normal limits. The patient s CMP was also within normal limits. ASSESSMENT AND PLAN: Patient was found under a bridge talking rapidly to himself and shaking uncontrollably. The crisis response team brought him in for an evaluation. When he arrived in the emergency room he appeared very anxious looking around the room, fixating on the machines. When the nurses tried to connect him to the monitors he lashed out and threatened to hurt them. He was given diazepam to calm him down and he was admitted to the psychiatric unit for a 72 hour evaluation. R/O Substance-induced mood disorder. The patient also appeared malnourished. A high calorie diet was ordered for his hospital stay. If this history and physical was performed prior to admission, but within the last 30 days, indicate by initialing one of the following: I have reassessed the patient and notes that there are no significant changes to the assessment. I have reassessed the patient and note the following significant changes occurred: DD: 08/12/ :25:20 DT: 08/12/ :17:29 CGHANYHSC; Job# Authenticated by Richard Freeman MD on 08/14/ :44:42 AM Richard Freeman Report ID: Electronically Signed by Richard Freeman on 08/14/2007 at 1052

9 County General Hospital 546 That Street Some Town, YY DISCHARGE SUMMARY PATIENT: Michael F. Byrnes UNIT#: ADMISSION DATE: September 18, 2011 ACCT#: DISCHARGE DATE: September 22, 2011 DOB: 05/19/78 ATTENDING PHYSICIAN: Freeman, Richard ROOM/BED: E. 134-C Isaac Johnson, DSA dictating for Dr. Richard Freeman DISCHARGE DIAGNOSES: 1. Schizophrenia 2. Posttraumatic Stress Disorder 3. Hepatitis C 4. Traumatic brain injury HISTORY OF PRESENT ILLNESS: This is a 33-year-old African American male with a recent history of psychosis and paranoia. Well known to this writer with frequent admissions to this hospital. He is currently homeless and was brought to the hospital after an altercation with police near Rickett s Glen Park. Patient is a veteran experiencing homelessness. He has persistent delusions about the government sending him messages and tracking his movements. He hears radio voices that are often threatening. He is distrustful of most people and technology. He has persistent headaches. PREVIOUS ADMISSIONS: 2011 August 1-3 Inpatient Psychiatric 2011 January 5-7 Inpatient Psychiatric 2010 November Inpatient Psychiatric 2010 February Inpatient Psychiatric 2009 November Inpatient Psychiatric 2009 January 9-11 Inpatient Psychiatric 2008 September Inpatient Psychiatric 2008 March 4-6 Inpatient Psychiatric 2007 August Inpatient Psychiatric ALLERGIES: No known drug allergies. HOSPITAL COURSE:

10 The patient was admitted to Unit E, placed on close observation and given a high-calorie diet. Patient is well known to the unit having been admitted 10 times over the last 4 years. Throughout his hospital course he was given haloperidol decanoate 10 mg due to a history of non-compliance with medications. He was also given paroxetine 20 mg and quetiapine 200 mg. Upon being admitted to the unit he denied auditory and visual hallucinations as well as suicidal and homicidal ideation. On 09/21/2011 he was calm and cooperative. He reported no complaints. His mood had stabilized. Therefore, on 09/22/2011 he was prepared for discharge. He is to receive aftercare at XYZ Community Mental Health Center. CONDITION AT DISCHARGE: Patient was alert and oriented x3. Vital signs were stable. He was discharged on September 22, 2011, with discharge instructions given and medications reconciled. DISCHARGE MEDICATIONS: 1. Haloperidol 10 mg 2. Paroxetine 20 mg 3. Quetiapine 200 mg 4. Levetiracetam 500mg DISCHARGE INSTRUCTIONS: Called the PATH team at XYZ Community Mental Health Center to follow-up with patient after discharge. Name of PATH caseworker given to patient and patient s sister, Catherine Daniels. Dictated by Issac Johnson DSA DD: 09/23/ :17:33 DT: 09/23/ :23:13 CGHANYHSC; Job# Authenticated by Richard Freeman MD on 09/24/ :13:43 PM