Patient arrives from outpatient clinic to be admitted (Voluntary) to inpatient facility: Patient is 33 yr. female who has been followed for depression over the past 6 months and is being admitted for acute mania. Currently on administrative leave from her employment as a certified account. Single and resides in parents’ home.
Present concern: Labile mood, insomnia, sporadic eating habits, difficulty maintain focus, distracted by external stimuli, grandiose thinking, more talkative than usual and currently has increased psychomotor activity.
History of Present Illness: Parents observed marked change in behavior (irritability, moodiness, being withdrawn) during undergraduate studies. Has maintained employment over the las eight years as an accountant following graduation from college. Diagnosed with anxiety and depression six weeks ago.
Patient reports: Changes in her behavior with moodiness becoming more pronounced. Began therapy with Fluoxetine (Prozac) 20 mg PO daily. After 3 weeks of treatment, still struggled at work, “Feeling downright miserable.” Provider increased dose of Fluoxetine to 20 mg PO BID.
Patient States: She began to experience insomnia, sleeping only 2-3 hrs. a night, increased goal driven activities, and distractibility.
Medications: Fluoxetine (Prozac) 20 mg PO BID, Zolpidem (Ambien) 10 mg PO at bedtime PRN insomnia.
Previous illness/surgery: No previous illness/ surgeries
Review of systems: Patient denies visual disturbances, reports no nausea, vomiting, trauma or chest pain. Does reports increased energy level.
Mood Disorder Questionnaire: Screened positive for possible bipolar disorder = Scored as Serious Problem.
Upon initial mental status: (thought content) of grandiose thinking, racing and magical thinking was evident. Information collected relates to episode of manic behavior. Patient presents with emotionally labile mood, laughing and joking, quickly followed by angry outbursts.
Patients behavior has become very unpredictable Patient is having problems with focusing such as eating and sleeping Patient demonstrates flight of ideas, loose association, rapid pressured speech impulsivity, and impaired judgement.
General Appearance: Client presents wearing brightly colored red dress and high heels for her 1300 appointment, excessive makeup, and excessive jewelry with many accessories. Frequently interrupts during interview, laughing inappropriately, becoming irritable with mother during interview.
The SMART (Specific ,Measurable ,Attainable ,Relevant and Time) goal for this patient are
Short term goal
The patient will have a normal body temperature -S/which will improve her general status-M/ with antipyretic medications-A/ now-R/ and will be normothermic in a day -T
Long term goal
The patient will exhibit normal cognitive behavior -S /good sleep pattern with appropriate treatment -M /with cognitive behavioral therapy and medication -A/ improve quality of life -R / in two to three weeks-T
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