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Document Type: Psychiatric Progress Note
Date of Service/Receive Date: January 17, 2022 13:01 EST
Document Status: Auth (Verified)
Document Title: BT1 Progress Note
Performed by: Waters, Amy – MD,Res,Psychiatry on January 17, 2022 13:05 EST
Verified by: Waters, Amy – MD,Res,Psychiatry on January 17, 2022 13:05 EST
Encounter info: 40020205734, JBHH, Inpatient, 1/14/2022 –

* Final Report *

BT1 Progress Note

JACK_FL

Patient: SOLA, EDUARDO MRN: 5561999 FIN: 40020205734

Age: 28 years Sex: Male DOB: 1/23/1993

Associated Diagnoses: None

Author: Waters, Amy – MD,Res,Psychiatry

Service performed as a moonlighter

 

Legal Status: Patient is voluntary and capacitated.

 

ID:

 Patient is a 28 y/o male with no formal pphx who presented to crisis voluntarily brought by family due to worsening mood sx and SI, admitted voluntarily for stabilization.

 

HPI:

Patient seen during morning rounds, case discussed with treatment team.

Per nursing, no acute events overnight. Pt adherent with meds and vitals, no behavioral issues.

 

Pt reports last night he was sleepy after taking meds but still had trouble falling asleep, received Ativan 1mg PRN with good benefit. He remains anxious and depressed with SI, but feels safe in the hospital and tolerating meds w/o SE. Agrees to continue titrating.

 

 Target Symptoms:

 Quality – mood swings, SI

 Severity – severe; danger to self

 Context – stress, no past psychiatric tx

 Modifying factors – hospitalization, medications, rest

 Associated signs & symptoms – as per HPI & MSE

 

Based on symptoms and behaviors described above :

-There is evidence of symptoms and behavior reflecting impairment, and continued treatment in an Inpatient setting is warranted at this time

-The patient is in continued need of psychiatric hospitalization , no less restrictive alternative is presently available   

-Pt continues to meet criteria for inpatient admission to BH Unit  

 

ROS:

Constitutional: denies fever or headache

Cardiac: denies chest pain or palpitations

Pulmonary: denies cough or SOB

GI: denies diarrhea or constipation

GU: denies dysuria or hematuria

MSK: denies myalgias

Neuro: denies tremors or paraesthesias

 

Vital Signs:

Vitals Signs/Measurements

Temperature Oral: 36.6 DegC Low

Peripheral Pulse Rate: 89 bpm

Respiratory Rate: 18 br/min

Systolic Blood Pressure: 108 mmHg

Diastolic Blood Pressure: 63 mmHg

SpO2: 99 %  

 

Labs:

WBC Count: 9.7 x10(3)/mcL (01/15/22)

RBC Count: 5.79 x10(6)/mcL High (01/15/22)

Hemoglobin: 17.7 g/dL High (01/15/22)

Hematocrit: 52.1 % High (01/15/22)

MCV: 90 fL (01/15/22)

MCH: 30.6 pg (01/15/22)

MCHC: 34 g/dL (01/15/22)

RDW-CV: 11.7 % (01/15/22)

Platelet Count: 307 x10(3)/mcL (01/15/22)

MPV: 10.6 fL (01/15/22)

NRBC%: 0 /100WBC (01/15/22)

NRBC%: 0 /100WBC (01/15/22)

NRBC(Abs): 0 x10(3)/mcL (01/15/22)

NRBC(Abs): 0 x10(3)/mcL (01/15/22)

Neutrophil (%): 73.7 % High (01/15/22)

Lymphocyte (%): 18.7 % (01/15/22)

Monocyte (%): 6 % (01/15/22)

Eosinophil (%): 0.5 % (01/15/22)

Basophil (%): 0.8 % (01/15/22)

Immature Granulocyte (%): 0.3 % (01/15/22)

Absolute Neutrophil: 7.1 x10(3)/mcL High (01/15/22)

Absolute Lymphocyte: 1.8 x10(3)/mcL (01/15/22)

Absolute Monocyte: 0.6 x10(3)/mcL (01/15/22)

Absolute Eosinophil: 0.05 x10(3)/mcL Low (01/15/22)

Absolute Basophil: 0.08 x10(3)/mcL (01/15/22)

Absolute Immature Granulocyte: 0.03 x10(3)/mcL (01/15/22)

Slide Review: Not Indicated (01/15/22)

TSH: 0.559 mcIU/mL (01/15/22)

Color: Yellow. (01/15/22)

Clarity: Turbid. Abnormal (01/15/22)

Specific Gravity: 1.02 (01/15/22)

Specific Gravity: 1.02 (01/15/22)

Urine pH: 7 (01/15/22)

Urine pH: 7 (01/15/22)

Protein: Negative: (01/15/22)

Glucose: Negative; (01/15/22)

Ketones: Negative: (01/15/22)

Bilirubin: Negative: (01/15/22)

Blood: Negative: (01/15/22)

Urobilinogen: Negative; (01/15/22)

Nitrites: Negative: (01/15/22)

Leukocyte Esterase: Negative: (01/15/22)

Urine Microscopic: Indicated Abnormal (01/15/22)

Urine WBC’s: <1 (01/15/22)

Urine WBC’s: <1 (01/15/22)

Urine RBC’s: 1 /HPF (01/15/22)

Urine RBC’s: 1 /HPF (01/15/22)

Bacteria: 0. (01/15/22)

Bacteria: 0. (01/15/22)

UA Amorph Phos: Present Abnormal (01/15/22)

Triphosphate Crystal: Present Abnormal (01/15/22)

SARS CoV 2 RNA, RT PCR: Negative, (01/15/22)

Cocaine & Metabolites: Not Detected (01/16/22)

Cannabinoid: Presumptive Pos Abnormal (01/16/22)

Benzodiazepine Class: Not Detected (01/16/22)

Opiate Class: Not Detected (01/16/22)

Amphetamine Class: Not Detected (01/16/22)

U Phencyclidine: Not Detected (01/16/22)

U Barbiturate Class: Not Detected (01/16/22)

U Methadone: Not Detected (01/16/22)

POC SARS CoV-2 Antigen: Negative` (01/15/22)  

Medication List:


Medications (6) Active

Scheduled: (2)

divalproex 500 mg Tab EC/DR 500 mg 1 tab, ORAL, BID

QUEtiapine IR 200 mg Tab 200 mg 1 tab, ORAL, BEDTIME

Continuous: (0)

PRN: (4)

hydrOXYzine pamoate 50 mg Cap 50 mg 1 cap, ORAL, Q6H

LORazepam 1 mg Tab 1 mg 1 tab, ORAL, BEDTIME

LORazepam 2 mg/mL Inj 1 mL 2 mg 1 mL, IM, Q6H

nicotine 2 mg Loz 2 mg 1 lozenge, TRANSMUCOSAL, Q2H  

 

MSE: 

Appearance/Behavior: appears stated age, fair hygiene / calm, cooperative

Orientation: AAOx3

Speech: clear, coherent, normal rate and tone

Eye Contact: good

Motor Activity: no PMR/PMA, no dystonic/tardive movements

Mood/Affect: anxious, depressed / mood congruent

Thought Process: goal directed

Thought content: 

– Hallucinations: denies AVH, does not appear RTIS

– Delusions/Preoccupations: none elicited

– SI/HI: denies

Insight/Judgment: limited/limited

Attention/Concentration: fair/fair

Memory: appears grossly intact

 

Level of risk: High

 

Justification for continued stay:

– Patient remains symptomatic and in need of further inpatient treatment and stabilization. Patient at risk of re-hospitalization or worsening of psychiatric symptoms in less restrictive environment.

 

Counseling provided:

– Diagnostic results/impressions and/or recommended studies

– Risks and benefits of treatment options

– Instruction for management/treatment and/or follow-up

– Importance of compliance with chosen treatment options

– Risk Factor Reduction

– Patient Education

– Prognosis

 

Coordination of care provided with:

– Nursing Staff

– Treatment Team

– Case manager

– Physician/s

 

  Diagnoses

Bipolar disorder, unspecified (F31.9)

Anxiety disorder, unspecified (F41.9)

End of Diagnoses List  

Plan

1. Legal Status: patient is voluntary and capacitated.

2. Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment. 

3. Patient was educated about reasons for prescribing the below listed medications, their expected benefits as well as potential side effects and relevant risks

4. Medications:


Medications (6) Active

Scheduled: (2)

divalproex 500 mg Tab EC/DR 500 mg 1 tab, ORAL, BID

QUEtiapine IR 200 mg Tab 200 mg 1 tab, ORAL, BEDTIME

Continuous: (0)

PRN: (4)

hydrOXYzine pamoate 50 mg Cap 50 mg 1 cap, ORAL, Q6H

LORazepam 1 mg Tab 1 mg 1 tab, ORAL, BEDTIME

LORazepam 2 mg/mL Inj 1 mL 2 mg 1 mL, IM, Q6H

nicotine 2 mg Loz 2 mg 1 lozenge, TRANSMUCOSAL, Q2H

5. Tobacco Cessation: NRT

6. Nursing Orders: encourage compliance with treatment plan, ADLs, groups

7. Labs/Imaging: reviewed as above

8. Consults: none indicated at this time

9. Court Date: n/a

10. Social Work: evaluation for disposition and follow-up

 

Clinical oversight provided by Dr. Dreize

Signature Line

Author: Waters, Amy – MD,Res,Psychiatry On: 01/17/2022 13:05 EST

Sent for Review: Dreize, Richard Michael – MD,Attn,Psychiatry


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