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Room South401A
Patient/Age/Sex P.O.//Male
Date of evaluation 10 March 2024
Allergies Ibuprofen
Admit date Jan 2023
Diagnosis Schizoaffective Type A Bipolar II
Legal status CONS
Chief complaint/concern (CC) (quoted: “In the patient’s words) The patient stated “I smoked crack and turned myself in, but the cops brought me here because they thought I was a crack addict” When patient was asked, they stated “I lash out” Patient states that he is told to become aggressive when someone doesn’t think his jokes are funny
Past psychiatric history
Anxiety. Hallucinations: Self-talk/self-laughter Mood swings: Verbal Aggression Inappropriate Behavior Delusions Grandiosity Depression History of Present Illness (HPI) HTN, Diabetes, Gout, Hyperprolactinemia, COPD
Alcohol/Tobacco/Drug history Alcohol Barbiturates Tobacco Cocaine Marijuana Heroin Vaping Inhalants Other: LSD Methamphetamines PCP IV Opioids Medical history HTN, Diabetes, Gout, Hyperprolactinemia, COPD
Diet Regulate diet.
Family history Unable to obtain
Constitutional review Temp: 97.8 Height: 70 inches
HR: 78 Weight: 207 lbs
BP & MAP: 119/
Resp rate: 12
Social history Educational level: Sophomore year of High School
Employment history: Author,Youtuber, and Stand-up comedian
Interpersonal relationships/support system:
4 Siblings and an Aunt
Musculoskeletal Examination
Muscle tone No impairment Dystonia Hypertonic/myoclonus Rigidity Flaccid
Gait Grossly normal Antalgic Limping In wheelchair Wide-based
Station Grossly normal Unsteady In wheelchair
Abnormal/Involuntary movements None Tremors Spasms Tics
Strength Greater than antigravity (>3/5) in all extremities Weakness:
Appearance Well-groomed Casual Disheveled Other:
Psychomotor behavior WNL Agitation Retardation EPS/tremors Involuntary movements Hyperactivity
Speech Spontaneous Slow Loud Rapid Other:
Attitude Cooperative Guarded Irritable Withdrawn Other:
Intelligence Average Above Below
Insight WNL Impaired
Mood Euthymic Depressed Anxious Irritable Other:
Affect Full Constricted Flat Labile Other:
Orientation Time Person Place Situation
Perception WNL Delusions Obsessions Phobias Other:
Memory test (3 Items) 3 2 1 0 out of 3 in 3 min
Judgement WNL Impaired
Thought content. WNL Hallucinations Auditory Visual Tactile Other:
Risk factors. Suicidal ideations Plan Denies Homicidal ideations Plan Denies
Thought process. Goal- oriented Concrete Tangential Circumstantial Other:
Concentration/Attention WNL Impaired
Recent memory WNL Impaired
Remote memory WNL Impaired
Medication Administration Record – provide most critical/priority psychiatric medications Generic & trade name Pharm class
Dose Route Freq Indication(s) r/t patient
Common SEs/ADEs (at least 3) Nursing considerations (at least 3)
Divalproex Sodium 1500 mg
PO Bed time
peripheral edema
Derm: alopecia, DRUG REACTION WITH EOSINOPHILIA AND
SYSTEMIC SYMPTOMS (DRESS), rash
EENT: visual disturbances
GI: abdominal
pain, anorexia, diarrhea, indigestion, nausea, vomiting,
constipation, HEPATOTOXICITY, PANCREATITIS
Hemat: thrombocytopenia, leukopenia
Metabolic: ↑ appetite, HYPERAMMONEMIA, weight gain
Seizures: Assess
location, duration,
frequency, and
characteristics of
seizure activity.
Institute seizure
precautions.
Bipolar
Disorder: Assess
mood, ideation, and
behavior frequently.
Migraine
Prophylaxis: Monitor
frequency and
intensity of migraine
headaches.
Quetiapine Fumarate 800 mg
PO Bed time
- Hallucinations
- Delusions (^) rash, hyperpigmentation
Assess for change
in severity of HIV
Mental Status Examination (MSE)
