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: Collette Rose UNIT#: ADMISSION DATE: June 5, 1995 ACCT#: DISCHARGE DATE: June 13, 1995 DOB: 12/04/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 346-B Issac Johnson, DSA dictating for Dr. Samantha Jackson DISCHARGE DIAGNOSES: 1. Major Depression 2. Alcohol Abuse HISTORY OF PRESENT ILLNESS: This is an 18-year-old Caucasian female with a recent history of major depression and suicide attempt. She ingested nearly an entire bottle of acetaminophen. Her sister discovered her passed out in the bathtub and called 911. She was brought to the emergency department by ambulance. She was admitted for further evaluation, stabilization and medication management. ALLERGIES: No known drug allergies. HOSPITAL COURSE: Treatment began in the ambulance on the way to the hospital. Activated charcoal was administered. Upon admission, gastric lavage was conducted to clean out the contents of her stomach. Patient s BAC level was She was given fluids to rehydrate her system after respiratory stabilization. On the morning of June 13, the patient had calmed down in response to the medication and care provided the last 7 days. She denied AH/VH. She denied any suicidal or homicidal ideations. She was prescribed fluoxetine 20mg, once daily. Dr. Jackson noted that she would need to follow up with social services and XYZ Community Mental Health Center for ongoing treatment. CONDITION AT DISCHARGE: The patient was wanting to be discharged. She was alert and oriented x3. Vital signs were stable. Her last recorded blood pressure was 107/61, heart rate 75. Lungs were clear. Abdomen was soft, nontender, nondistended with positive bowel sounds. She was

2 discharged on June 13, 1995, 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. Fluoxetine 20 mg DISCHARGE INSTRUCTIONS: Follow up with Social Services as instructed r.e. housing. Follow-up with XYZ Community Mental Health Center for ongoing treatment. Dictated by Issac Johnson DSA DD: 06/14/ :25:34 DT: 06/14/ :15:25 CGHANYHSC; Job# Authenticated by Samantha Jackson MD on 06/15/ :45:21 PM

3 County General Hospital 546 That Street. Some Town, YY HISTORY AND PHYSICAL REPORT PATIENT: Collette Rose UNIT#: ADMISSION DATE: June 5, 1995 ACCT#: ADMITTING PHYSICIAN: Jackson, Samantha DOB: 12/04/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 346-B DICTATING PHYSICIAN: Jackson, Samantha CHIEF COMPLAINT: The patient came in with major depression following a suicide attempt. HISTORY OF PRESENT ILLNESS: This is an 18-year-old Caucasian female with major depression. She complains of feelings of hopelessness. She has lost interest in every day activities that used to bring her joy, including caring for her son. She is sleeping hours a day and not caring for her hygiene. She complains of little energy. She reports that she has lost 15 lbs in the last month. She appears to be underweight for her height. PAST MEDICAL HISTORY: The patient has a prior suicide attempt as a juvenile. In 1991, when the patient was 13 years old she took an entire bottle of acetaminophen to stop the pain. SOCIAL HISTORY: She is single, she recently had a son, is currently unemployed and homeless. She 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: PHYSICAL EXAMINATION: GENERAL: The patient is lying in the bed, quietly crying. Occasionally sleeps.

4 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, s1, s2 heard. No murmurs, 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 Fluoxetine 20 mg to stabilize. The patient will get social worker involved for further plan of care. We will start the patient on antidepressant 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 06/07/1995 at 0932

5 County General Hospital 546 That Street. Some Town, YY DISCHARGE SUMMARY PATIENT: Collette Rose UNIT#: ADMISSION DATE: January 5, 2012 ACCT#: DISCHARGE DATE: January 8, 2012 DOB: 12/04/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 346-B Issac Johnson, DSA dictating for Dr. Samantha Jackson DISCHARGE DIAGNOSES: 1. Bipolar I Disorder, most recent episode, manic 2. Alcohol Abuse HISTORY OF PRESENT ILLNESS: This is a 33-year-old Caucasian female with a recent history of bipolar disorder, manic episode. She was picked up by a patrol call when business owners reported her harassing their patrons as she yelled at them to buy a copy of her book. She was talking rapidly, could not focus on questions and began hyperventilating. She was admitted for further evaluation, stabilization and medication management. PREVIOUS ADMISSIONS: 2011 March Inpatient Psychiatric 2010 April Inpatient Psychiatric 2007 August 1-3 Inpatient Psychiatric 2007 Jan 1-3 Inpatient Psychiatric 2006 June Inpatient Psychiatric 2005 Feb Inpatient Psychiatric 2004 Sept 1-4 Inpatient Psychiatric 2003 Dec Inpatient Psychiatric 2001 Nov 6-10 Inpatient Psychiatric 2000 Mar Inpatient Psychiatric 1997 Feb Inpatient Psychiatric 1995 June 5-3 Inpatient Psychiatric 1991 May 6-10 Inpatient Psychiatric ALLERGIES: No known drug allergies.

6 HOSPITAL COURSE: Patient was admitted to the psychiatric unit for stabilization on medication. She was placed under close observation and given a regular diet. Her breathing calmed once she was placed in a bed but she continued to tell the nurses about the book and the book tour that she was going to go on with her daughter. Her pressured speech and delusions of grandeur lasted for the first 48 hours. On the morning of January 8th, the patient had stabilized in response to the medication and care provided the last 3 days. She denied AH/VH. She denied any suicidal or homicidal ideations. She was prescribed Lamictal 300 mg and Seroquel 100 mg to help her sleep. She was prescribed metoprolol tartrate 100 mg for her hypertension. Dr. Jackson noted that she would need to follow up with social services and XYZ Community Mental Health Center for ongoing treatment. CONDITION AT DISCHARGE: The patient was wanting to be discharged. She was alert and oriented x3. Vital signs were stable. Her last recorded blood pressure was 140/90, heart rate 75. Lungs were clear. Abdomen was soft, nontender, nondistended with positive bowel sounds. She was discharged on January 8, 2012, with discharge instructions given and medications reconciled. LABORATORY DATA: On January 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. Lamictal 300 mg, po opd 2. Seroquel 100 mg, po qhs 3. Metoprolol tartrate 100 mg, po opd DISCHARGE INSTRUCTIONS: Follow up with Social Services as instructed r.e. benefits application and housing. Follow-up with XYZ Community Mental Health Center for ongoing treatment. Dictated by Issac Johnson DSA DD: 01/09/ :25:34 DT: 01/09/ :15:25 CGHANYHSC; Job# Authenticated by Samantha Jackson MD on 01/11/ :45:21 PM

7 County General Hospital 546 That Street. Some Town, YY HISTORY AND PHYSICAL REPORT PATIENT: Collette Rose UNIT#: ADMISSION DATE: January 5, 2012 ACCT#: ADMITTING PHYSICIAN: Jackson, Samantha DOB: 12/04/78 ATTENDING PHYSICIAN: Jackson, Samantha ROOM/BED: F. 346-B DICTATING PHYSICIAN: Jackson, Samantha CHIEF COMPLAINT: The patient was brought to the hospital because of a public disturbance. She is experiencing a manic episode. HISTORY OF PRESENT ILLNESS: This patient has a known history of bipolar disorder. She has a long history of mood swings for the past several years. She has been on Lithium and Lamictal and she has been noncompliant with medications. For the past few weeks she has had depressed mood, she was anhedonic, had decreased energy, decreased appetite and difficulty falling and maintaining sleeping. In the last few days she has been experiencing a manic episode. Officers report a change in her demeanor. She has been attending the County Probation Alternatives Program and is currently sober, but is not taking any medications. She has delusions of grandeur and pressured speech. She is not able to focus on a line of questions or one topic. She is preoccupied with sharing information about a supposed book that she has written and how she is going to use the proceeds to take her daughter on a book tour to Europe. She denies any auditory hallucinations during the interview. She denies any suicidal or homicidal ideation. PAST MEDICAL HISTORY: The patient has prior suicide attempts as a juvenile and young adult. She has been diagnosed with major depression and bipolar disorder. Her most recent episode is manic. Records indicate that she has diabetes and high blood pressure. SOCIAL HISTORY: The patient was born in Middleton, PA and spent most of her adult life in Any Town. The patient is currently experiencing homelessness. She is single and has 2 kids who are not currently in her custody. She has a sister who she maintains contact with. She has an 8 th grade education and is unable to maintain employment. She has a significant history of physical and sexual abuse. No military history. FAMILY HISTORY:

8 MEDICATIONS: REVIEW OF SYSTEMS: All other systems are reviewed, otherwise negative. ALLERGIES: PHYSICAL EXAMINATION: GENERAL: The patient is lying in the bed quietly talking to herself. VITAL SIGNS: Significant for patient s temperature of 99.2, pulse of 88, respiratory rate of 18, blood pressure of 150/91, 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, s1, s2 heard. No murmurs, 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. Tox screens were negative for alcohol. ASSESSMENT AND PLAN: Mania. The patient will be given Lamictal 300mg to stabilize. The patient will get social worker involved for further plan of care. We will start the patient on Seroquel to aid her sleep. Hypertension. The patient was given metaprolol tartrate 100mg to control her blood pressure. 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: 01/07/ :25:30 DT: 01/07/ :14:09 CGHANYHSC; Job# Authenticated by Samantha Jackson MD on 01/08/ :49:45 AM

9 Samantha Jackson Report ID: Electronically Signed by Samantha Jackson on 01/08/2012 at 0932