Discharge Summary Patient H Sample Ken Cure MD
PRIMARY DIAGNOSIS bipolar affective disorder as of 26 March 2006
Treatment Dates June 12, 2006 - September 30, 2006
Plan Dates June 22, 2006 - September 22, 2006
Frequency of Visits 3 times per week
DIAGNOSIS ADDRESSED BY PLAN bipolar affective disorder
Prior Hospitalizations March 26, 2006 - March 29, 2006
PMH + Prior Function PATIENT HAS HAD MULTIPLE PSYCHIATRIC HOSPITALIZATIONS OVER MANY YEARS, MOST RECENTLY 2 INPATIENT ADMISSIONS TO GENERAL HOSPITAL FOR SUICIDAL IDEATION AND SEVERE ANXIETY. PATIENT HAS BEEN UN OR UNDEREMPLOYED SINCE SUICIDE DEATH OF HIS TWIN BROTHER.
Initial Assessment PATIENT IS EXTREMELY ANXIOUS, AGITATED AND NEEDY, CANNOT HOLD EMPLOYMENT, HAS DIFFICULTY ATTENDING PROGRAM REGULARLY, AND CANNOT SIT IN GROUPS FOR 10 MINUTES AT A TIME. RETURNS TO HOSPITAL INPATIENT WARDS WHENEVER ANXIETY BECOMES OVERWHELMING, WHICH IS OFTEN.
Progress PROGRESS915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATE IN SYMPTOMMANAGEMENT GROUP. PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50% LONGER. LAB WORK DONE ON 07/17/00
LITHIUM LEVEL 90
ROUTINE MONITORING OF THERAPEUTIC RESPONSE. GOALS PATIENT IS WORKING TO COME UP WITH ALTERNATIVES TO INPATIENT HOSPITALIZATION WHEN HE FEELS ABANDONED OR ANXIOUS PATIENT IS EXPECTED TO RETURN TO THE LEVEL OF EMPLOYMENT THAT IS COMMENSORATE WITH HIS COGNITIVE ABILITIES.
Plan 915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT 3X WEEK WITH PSYCHOLOGIST LAB WORK 1X MONTH: TO MONITOR LITHIUM FOR THERAPEUTIC LEVEL.
Medications
Medication Dose Route Frequency
LITHIUM LEVEL 600 MG PO QAM
LITHIUM LEVEL 900 MG PO QHS
THIOTHIXENE 5 MG PO TID
BENZTROPINE 1 MG PO TID
INDOMETHACIN 50 MG PO TID
LITHIUM LITHIUM THIOTHIXENE BENZTROPINE INDOMETHACIN
Continued Treatment PATIENT HAS ACTIVE ANXIETY SYMPTOMS AND SUICIDAL IDEATION AND REQUIRES THIS LEVEL OF CARE TO HELP PREVENT RELAPSE AND INPATIENT TREATMENT.
Reason for Admission PATIENT HAD SEVERAL RECENT PSYCHIATRIC HOSPITALIZATIONS FOR ANXIETY AND SUICIDAL IDEATION, AND REQUIRED THE SUPPORT AND STRUCTURE OF DAY HOSPITAL PROGRAM TO PREVENT RELAPSE AND REHOSPITALIZATION.
Symptoms and Behavior PATIENT WAS AGITATED, ANXIOUS AND NEEDY, EXPRESSING FEARS OF ABANDONMENT AND PASSIVE SUICIDAL IDEATION. PATIENT REQUIRED FREQUENT REINFORCEMENT IN ORDER TO CONTINUE TO FUNCTION OUTSIDE OF AN INPATIENT PSYCHIATRIC WARD.