We MI LLWOOD 8 PI 1' A. L, AND THE EXCEL CENTER DISCHARGE SUMMARY PATIENT NAME: Samantha Trimhle PHYSICIAN: MEDICAL RECORD 61866 DATE OF ADMISSION: 10/26/2012 DATE OF DISCHARGE: 10/29/2012 DISCHARGE DIAGNOSES AXIS I: MOOD DISORDER NOT OTHERWISE SPECIFIED, LIKELY BIPOLAR MOOD DISORDER, WITH MANIC AND EPISODE, THE PATIENT NEEDS FURTHER EVALUATION TO DETERMINE THAT. AXIS II: DEFERRED, AXIS OSTEOPOROSIS ASTHMA MIGRAINE. AXIS IV, SOCIAL, AXIS V: GAF: 30 TO 35, PERTINENT FOR ADMISSION: This 34-year-old divorced white female was hospitalized to Millwood Hospltal after voicing suieidal statements to her minister after she had a conflict at work, For details, please see the evaluation, PHYSICAL EXAMINATION: The patient has migraine, Osteoporosis. and asthma LABORATORY INVESTIGATIONS: Labs are not on the chart at the time ofdictation. TREATMENT COURSE: The patient was hospitalized and enrolled in therapeutie milieu. she was kept on suicide precaution. The patient remained very defensive and wanting to leave. minimizing all the episodes that happened in school and Very angry that she is being disciplined instead ofher boss and her supervisor's dealing with the children and the children's parents. The patient described all the events in very much details. and stated that she has been doing exactly how she should be but people do not like her guts nr does Ilct appreciate what she does and now she is at the brink oflosing everything. She stated that she was at the brink of losing herjob, her house. and her daughter; and she stated that she was panicking. The patient was reporting that she was doing, overall, okay, she enjoyed belng home with her daughter and she did not like much interaction with people but at this point, she felt overwhelmed as she was here in the hospital and she did like bemg in the hospital, She felt that she did not belong here, and she was endorsing depressive Page 1 at 1? 109?? <21, PATIENT NAME: Samantha Trimble MEDICAL RECORD 61866 DATE OF ADMISSION: 10/26/2012 DATE OF DISCHARGE: 10/29/2012 DISCHARGE SUMMARY for which Zoloft was started and trazodone was given to sleep at night as the patient was endorsing very much dif?culty sleeping at night. The next day, the patient decided that she did not belong here and she wanted to leave. She was put on a hold for further evaluation. The patient remained extremely labile and agitated, and she continued to instigate other patients and getting all other patients and telling them that they should all sign AMA and get out of the hospital stating that none of them belong in the hospital; and she was very disruptive to the entire unit, very intrusive, and very loud. After several patients complained about it at night, yesterday, the patient was moved to plCU. The patient?s mother had come for family therapy. Apparently, the mother was supportive and wanted the patient out as well. There were several phone calls back and forth with nursing and the nursing supervisors due to the patient and the patient?s family focusing on her getting out of the hospital rather than addressing her emotional issues and giving her appropriate medication. Apparently, it was very clear that the patient did seem to be heading?i??i episode and needed a mood stabilizer; although, she was not willing to take the treatment here and wanted to leave. She wanted to go through the medical records. Considering her behavior and her emotional status, the patient was still un?t to review the records at this point. She de?nitely has a right to review the records after getting out of the hospital, when getting the records from the medical records would be perfectly fine. The patient was writing each and every word that I told her, trying to write it down, trying to remember what I told her yesterday or the day before yesterday, and trying to write that down and was asking me a question as if she was cross-examining me. She also made a comment that she belongs to Mensa and she is very smart with an IQ of 140 plus, and she thought that others here were beneath her. The patient was not ready or open or in a right frame of mind to accept the treatment at this point. The patient was having episode but at this point, she was not suicidal or homicidal so I do not have a reason to hold her against her will at this point but I told the patient and I do believe that by not getting the treatment, she was doing disservice to herself. Definitely, the patient will be doing much better with the appropriate medication management which she can do as an outpatient at this point. It will be preferable to monitor her more closely in the inpatient setting but since the patient was not in imminent danger to self or others at this point, we will be discharging her at the patient?s request. MENTAL STATUS EXAMINATION ON DISCHARGE: The patient was alert and oriented x3. She was carrying her belongings around, paranoid, intrusive, demanding, and sarcastic. She denied any suicidal or homicidal ideation. She was somewhat emotional and attempting to keep her emotions in check. She was intrusive with the peers on the unit and needing redirection. She denied hallucination. Paranoia was evident. Memory and concentration were grossly intact. Insight and judgment were poor. DISCHARGE MEDICATIONS: Prescription was given for trazodone 50 mg at night, one-month prescription, no re?ll. Zoloft has been discontinued after giving her just one dose as at this point giving her Zoloft might make her manic worse, which is not appropriate treatment at this point. The patient rather needs a mood stabilizer, but the patient is not willing to take any at this point. Continue her Vivactil 10 mg in the morning every other day, Page 2 of 3 PATIENT NAME: Samantha Trimble MEDICAL RECORD 61866 DATE OF ADMISSION: 10/26/2012 DATE OF DISCHARGE: 10/29/2012 DISCHARGE SUMMARY Flovent 220 meg two puffs in the moming. acyclovir 200 mg daily, and Relan 20 mg if the patient has a headache, The patient had been given Zithmmax while she had been here, and course had been completed. DIET RESTRICTIONS: Regular ACTIVITY RESTRICTIONS: Ad lih, DISCHARGE FOLLOWUP: The patient is encouraged to seek outpatient treatment at Excel Program, which the patient has declined. The patient is declining to allow to schedule any outpatient appointman and the patient has an appointment with the therapist, Jameson Frances. on 10/30/2012 at II in the moming. PROGNOSIS: Guarded at this point as the patient actually needs to he in the hospital and have further evaluation and have proper medication adjustment and management but as the patient is requesting to leave and she IS not suicidal or homicidal at this point, I will be discharging the patient hoping that she would seek outpatient treatment. a] 3 77v lb PHYSICIAN signature: 1 Date and Time Signed: DR: SM:epm/cpm DD: 10/29/2012 0356 PM r: 10/30/2012 07:05 AM Job 1493427 Page 3 063