Week 5 Patient 1 follow instructions must be original no plagiarism due 1/19/2022 at 6 pm

Document Type:

Psychiatric Progress Note

Date of Service/Receive Date:

November 08, 2021 07:31 EST

Document Status:

Modified

Document Title:

CAAP Progress Note

Performed by:

Alrojolah, Loay - MD,Res,Psychiatry on November 08, 2021 07:35 EST

Verified by:

Alrojolah, Loay - MD,Res,Psychiatry on November 08, 2021 10:28 EST

Encounter info:

40019956532, JBHH, Inpatient, 11/5/2021 -

Subjective Mark Jones is a 13 y/o boy with multiple psychiatric diagnoses - ODD, ADHD, DMDD, IED, possible bipolar disorder, and borderline personality disorder. He is admitted involuntarily for aggressive behavior at school. Of note, patient physically assaulted teacher who required medical attention and has decided to press charges against him. I saw patient in follow-up this morning, received overnight sign-out and nursing report. Received PRN for aggressive behavior this morning. On interview, pt calm, cooperative with poor eye contact, moving around during the interview process. He reports remorse over the incident that happened (despite stating that while smiling) and cites being "emotionally upset" about discussing his biological mom with the therapist the day prior to the incident as the inciting factor to his aggressive behavior. Patient denied mood symptoms of depression, anxiety or mania. Patient denies AH, VH and does not endorse gross delusions. Patient adamantly denied current suicidal and homicidal ideation, plan, intent or attempt. Patient tolerating medications with no side effects. Side effects from medications : n/a Compliance with treatment : yes Any ETO’s PRN’s: No Aggression: YES Sleeping : fairly Insight / judgment: limited /limited Suicide: denied Homicide: denied Based on symptoms and behaviors described above: -There is evidence of symptoms and behavior reflecting impairment, and continued treatment in an inpatient psychiatric setting is warranted at this time -No less restrictive alternative is presently available -Patient continues to meet criteria for inpatient admission to BH Unit Review of Systems Review Of Systems: 1. Neurological- negative 2. Integumentary- negative 3. Cardiovascular- negative 4. Respiratory- negative 5. Endocrine- negative 6. Gastrointestinal- negative 7. Genitourinary- negative 8. Hematologic- negative 9. Immunologic- negative 10. ENT- negative 11. Ophthalmologic- negative 12. MSK- negative **Patient has no new physical or medical complaints or concerns at this time. Physical Exam Vital Signs (last 24 hrs)_____ Last Charted___________ Temp Oral 36.8 DegC (NOV 08 06:00) Heart Rate Peripheral 82 bpm (NOV 08 06:00) Resp Rate 18 br/min (NOV 08 06:00) SBP 90 mmHg (NOV 08 06:00) DBP 53 mmHg (NOV 08 06:00) SpO2 99 % (NOV 08 06:00) Mental Status Exam - Sensorium: awake, alert, oriented to time, place, and person - Appearance and Behavior: appears stated age, calm, cooperative, wearing own clothes, no acute distress - Motor: No PMA/PMR_ - Eye Contact: appropriate - Speech: regular rate, volume, prosody, comprehensible - Mood: irritable - Affect: mood-congruent, full range - Thought process: linear, goal-directed - Thought content: - Delusions: none elicited - Mood Symptoms: did not report - Obsessions and/or Preoccupations: preoccupied with discharge - Anxiety: did not report - Perceptual Disturbances - Hallucinations: does not appear RTIS - Suicidal thoughts/intent/plan: no objective evidence - Homicidal thoughts/intent/plan: no objective evidence - Insight/Judgment: poor/poor - Attention & Concentration: attentive, good - Memory: grossly intact - Language: fluent - Fund of knowledge: baseline Assessment/Plan 1. Patient continues to require 24-hour observation, nursing care, and inpatient treatment and cannot be treated in a less restricted environment. 2. Complexity of data: Reviewed clinical labs. Reviewed imaging results. Old records reviewed. Case discussed with other medical providers 3. Nursing orders: Encourage compliance with treatment plan, ADLs, groups. 4. Medication: Medication List Active Medications Ordered acetaminophen: 650 mg, 2 tab, ORAL, Q6H, PRN: Pain - Mild. chlorproMAZINE: 25 mg, 1 mL, IM, Q6H, PRN: Agitation. diphenhydrAMINE: 50 mg, 1 mL, IM, Q6H, PRN: Agitation. divalproex sodium: 500 mg, 1 tab, ORAL, BID. divalproex sodium: 250 mg, 1 tab, ORAL, BEDTIME. guanFACINE: 1 mg, 1 tab, ORAL, BID. magnesium hydroxide: 30 mL, ORAL, Q12H, PRN: Constipation. PARoxetine: 20 mg, 1 tab, ORAL, DAILY. risperiDONE: 3 mg, 1 tab, ORAL, BEDTIME. risperiDONE: 3 mg, 1 tab, ORAL, QAM. TrazODONE: 100 mg, 1 tab, ORAL, BEDTIME. Prescribed divalproex sodium: 500 mg, 1 tab, ORAL, BID, for 30 day(s), 60 tab, 0 Refill(s). divalproex sodium: 250 mg, 1 tab, ORAL, BEDTIME, for 30 day(s), 30 tab, 0 Refill(s). guanFACINE: 1 mg, 1 tab, ORAL, BID, for 30 day(s), 60 tab, 0 Refill(s). PARoxetine: 20 mg, 1 tab, ORAL, DAILY, for 30 day(s), 30 tab, 0 Refill(s). risperiDONE: 2 mg, 1 tab, ORAL, DAILY, for 30 day(s), 30 tab, 0 Refill(s). risperiDONE: 3 mg, 1 tab, ORAL, BEDTIME, for 30 day(s), 30 tab, 0 Refill(s). TrazODONE: 100 mg, 1 tab, ORAL, BEDTIME, for 30 day(s), 30 tab, 0 Refill(s). Medications Inactivated in the Last 72 Hours chlorproMAZINE: 25 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion Form. chlorproMAZINE: OVERRIDE, ONCE. influenza virus vaccine, inactivated: 0.5 mL, IM, BEFORE DISCHARGE. 5. Patient Instructions: Encouraged compliance with medications, Benefits and side effects of medications were discussed, Encouraged reporting side effects to nursing and medical staff 6. Social work evaluation for disposition and follow up

Lipid Profile:

Urinalysis:

Triglyceride: 222 mg/dL (10/27/21)

: ()

Urine Blood: Neg mg/dL (11/07/21)

Cholesterol, Total: ------

Nitrites: Neg (11/07/21)

Protein: 30 (11/07/21)

HDL POC: ------

Ketones: 10 mg/dL (11/07/21)

Urine Color Urine Dipstick: ------

LDL POC: ------

Leukocyte Esterase: Neg (11/07/21)

: ()

Bilirubin: Neg mg/dL (11/07/21)

Urine pH: 6.5 (11/07/21)

Urobilinogen: Negative mg/dL (11/07/21)

Specific Gravity: 1.034 (11/07/21)

Amphetamine Class: Not Detected (11/07/21)

Bacteria: 0 (11/07/21)

Benzodiazepine Class: Not Detected (11/07/21)

Calculated LDL: 112 mg/dL (10/27/21)

Cannabinoid: Not Detected (11/07/21)

Cholesterol: 189 mg/dL (10/27/21)

Clarity: Clear (11/07/21)

Cocaine & Metabolites: Not Detected (11/07/21)

Color: Yellow (11/07/21)

Glucose: Negative mg/dL (11/07/21)

Glycohemoglobin: 5.1 % A1C (10/27/21)

HDL: 33 mg/dL (10/27/21)

Mucous: 1+ (11/07/21)

Opiate Class: Not Detected (11/07/21)

SARS CoV 2 RNA, RT PCR: Negative (11/05/21)

Sperm: Present (11/07/21)

U Barbiturate Class: Not Detected (11/07/21)

U Methadone: Not Detected (11/07/21)

U Phencyclidine: Not Detected (11/07/21)

Urine Microscopic: Indicated (11/07/21)

Urine RBC's: 5 /HPF (11/07/21)

Urine WBC's: 3 /HPF (11/07/21)