Patient description
The patient is a 37-year-old Caucasian female with a history of asthma, breast biopsies, contusion to head with LOC, HPV, and Hypothyroidism, who was admitted to the hospital after assaulting her mother and stepfather. She is diagnosed with bipolar I disorder with current or most recent episode of mania.
History of present illness Patient states, “I have been suffering for 20yrs, dated a guy for 6yrs and was raped every day. I always put myself in mental institutions for bipolar disorder”. Patient came to the hospital voluntarily. She had a pelvic surgery for endometriosis on the 11th of August 2015. Patient reports having excruciating pain in her hip and her bones feel like they are breaking from inside. Patient has been taking …show more content…
Plan on living in white house
Suicidal Ideation: Patient denies thought of harming herself.
Homicidal Ideation: Patient denies thought of harming other people.
Thought process: Patient thought process is tangential, circumstantial, and flight of ideas.
Memory: Patient recalls 3/3 objects, provides a recollection of the past 24 hours, and is able to report when she was admitted to the unit.
Intellect and Fund of Knowledge: Patient present as knowledgeable about current events. Abstract - states “be careful how you treat others because you don’t know who you might end up hurting” in response to “people in glass houses shouldn’t throw stones”.
Insight: Good. Patient states she came to the hospital voluntarily so as to get treatment.
Judgment: Good. When asked what she would do when she finds a stamped, addressed envelope lying on the ground, she states “put it in mailbox”.
Mini-Mental Status Exam (MMSE): Not able to assess all but she did score a 10/10 on orientation, 3/3 on registration, and 3/3 on recall.
Diagnoses
Severe depression
Rash
Pelvic surgery for endometriosis
Allergies: Haldol, Sulfa drugs, Lithium, and Benadryl.
Nursing
The patient is a 37-year-old Caucasian female with a history of asthma, breast biopsies, contusion to head with LOC, HPV, and Hypothyroidism, who was admitted to the hospital after assaulting her mother and stepfather. She is diagnosed with bipolar I disorder with current or most recent episode of mania.
History of present illness Patient states, “I have been suffering for 20yrs, dated a guy for 6yrs and was raped every day. I always put myself in mental institutions for bipolar disorder”. Patient came to the hospital voluntarily. She had a pelvic surgery for endometriosis on the 11th of August 2015. Patient reports having excruciating pain in her hip and her bones feel like they are breaking from inside. Patient has been taking …show more content…
Plan on living in white house
Suicidal Ideation: Patient denies thought of harming herself.
Homicidal Ideation: Patient denies thought of harming other people.
Thought process: Patient thought process is tangential, circumstantial, and flight of ideas.
Memory: Patient recalls 3/3 objects, provides a recollection of the past 24 hours, and is able to report when she was admitted to the unit.
Intellect and Fund of Knowledge: Patient present as knowledgeable about current events. Abstract - states “be careful how you treat others because you don’t know who you might end up hurting” in response to “people in glass houses shouldn’t throw stones”.
Insight: Good. Patient states she came to the hospital voluntarily so as to get treatment.
Judgment: Good. When asked what she would do when she finds a stamped, addressed envelope lying on the ground, she states “put it in mailbox”.
Mini-Mental Status Exam (MMSE): Not able to assess all but she did score a 10/10 on orientation, 3/3 on registration, and 3/3 on recall.
Diagnoses
Severe depression
Rash
Pelvic surgery for endometriosis
Allergies: Haldol, Sulfa drugs, Lithium, and Benadryl.
Nursing