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Case Note Record of Key Worker Session - Essay Example

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Case note record of key worker session Date: Dec 01, 2011 Patient name: Dennis Cooper This case note is to describe an incident, which occurred tonight, with Mr. Dennis Cooper, age 45, the patient admitted in room 2002. Since the key worker Ms. Chen was away on an emergency, I had taken over her duties for the night…
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Download file to see previous pages When I inquired about the reason of his insomnia, he informed me that he had been undergoing a lot of stress for the past few days, especially when he stayed with his mother in her house. Since his mother is unemployed, she heavily relies on him for monthly expenses and tends to get abusive, if he does not provide adequately. This has been constant practise for the past 2 months. Since he has high respect and regard for her, he is unsure about how to handle the situation. According to him, the insomnia stems from the fact that he constantly thinks about ways to make additional money to support his mother’s lifestyle. Now its come to a point where he is unable to deal with it anymore, and admitted that as his discharge day gets closer, he is getting increasingly worried about moving in back to his mother’s house. He expressed his desire to buy a house for and live there by himself. He himself suggested that it would be a great way to address his insomnia and bipolar disorder that he had been admitted for. Mr. Cooper said that he would often move to his friend’s apartment for a few days to clear his mind, when things got worse with his mother. Clearly, one of the reasons for Mr. Cooper’s insomnia and phases of depression is due to his unhappiness when with his mother. I suggested him a counseling session with one of the doctors at the department of psychology. In my opinion, these findings and revelations could be new leads in diagnosing Mr. Cooper’s condition, and prompt action should be taken, before his discharge, which is scheduled on the 3rd of December. Sincerely, Head nurse, Department of Psychiatry Discharge Summary Patients name: Dennis Cooper Age: 45 years Condition: Bipolar disorder Discharge time: 12:45 pm, December 3rd, 2011 Summary: A 45-year old male was admitted due to severe depression and an attempted, failed suicide on November 25th, 2011 at 4pm, by an overdose of Diazepam. The patient is a known case of Bipolar II disorder. On admission, he was immediately given a gastric lavage. Following the lavage, vital parameters were normal, and BP was 120/80. On awakening, the patient started talking incessantly, smiling constantly and seemed very excited and elated. This lasted for approximately 3 hours, after which he fell asleep. After awakening from a 6-hour nap, the patient had a severe headache, which subsided after administration of Advil, however, he was sobbing inconsolably for no apparent reason and appeared dejected and low. In order to relieve this phase of depression, Divalproex, clonazepam and Lithium were commenced. No more of such acute episodes of either mania or depression were observed during the course of his stay. The patient was under moderate sedation and antidepressants throughout his stay at the center, and this combination was helpful in maintaining a neutral state of mind, without any agitation or depression. On December 1st, he underwent counseling with the department of psychiatry, about certain issues, which in his opinion were causes for his insomnia and bipolar syndrome. A follow up with Dr. Shinde is recommended after a week of discharge. The current medication sheet that he is currently prescribed and needs to be continued is attached with this summary sheet. Medication: Lithium: 0.5 mg OD Divalproex: 250 mg BD Clonazepam: 0.25 mg BD Follow up: Dec. 11, Community Hospital Attending physician: Dr. Jay Shinde Comments: In case of sudden ...Download file to see next pagesRead More
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