CC (chief complaint): The weekend was stressful, but in a manageable way
HPI: HPI: A.B 18-week pregnant 30year old and 18-week pregnant female who was admitted following increasing anxiety, mood disturbance and psychosis. She was quite paranoid and seemed hesitant upon approach. She was easily distracted by the voices of others in the hallway. She demanded to know why there were people gathering outside the door. She continues to display labile mood, paranoia and overt evidence of psychosis, and shows unpredictable behaviors. She was offered one-to-one monitoring, and she expressed feeling as if a one-to-one monitor would help her to feel safer. The patient was restless and pacing requiring PRN Ativan, which helped calm her and return her to sleep. She reports decreased intensity of AH, stating that she continues to hear command AH endorsing harm to herself but that she can ignore it. She denies any desire or thoughts to harm herself or her fetus, and feels she is thinking “more clearly.” She slept “great” and her mood is “drastically improved” as she is no longer scared on the unit and less sad. She reports feeling best when she keeps busy, and found the downtime over the weekend “stressful.” She was able to cope by reading books and speaking with her parents, who visited her and are supportive. She denies VH/SI/HI, and feel medications are helping her. She denies medication side effects.
Substance Current Use and History: No history of substance abuse
Past Psychiatric History: History of bipolar disorder 1, and has been non-compliant for 3-4 months after discovering she was pregnant. She has been attending some of group therapy sessions
· Current Facility-Administered Medications
· Medication Dose Route Frequency Last Admin
· Olanzapine zydis (ZyPREXA) disintegrating tablet 10 mg 10 mg oral Nightly 10 mg at 03/22/21 2049
· Olanzapine zydis (ZyPREXA) disintegrating tablet 5 mg 5 mg oral QAM 5 mg at 03/23/21 0913
· prenatal multivitamin 29 mg iron- 1 mg tablet 1 tablet 1 tablet oral Daily 1 tablet at 03/23/21 0913
· Lorazepam (ATIVAN) tablet 2 mg 2 mg oral Q6H PRN 2 mg at 03/22/21 2049
· Olanzapine (ZYPREXA) tablet 2.5 mg 2.5 mg oral BID PRN
Medical History: flu vaccine 2020-21(4 years & up)(PF) QV (FLUCELVAX) IM injection 0.5 mL 0.5 mL intramuscular During hospitalization
Allergies: No known allergies
Reproductive Hx: 18weeks pregnancy, and had stopped taking medication after knowing she was pregnant
Psychiatric ROS: +AH, no SI/HI/VH
- Nurse report: She slept for 6.5hrs, has been medication compliant since admission
- BP: (111-115)/(67-68) 115/67
- Heart Rate: [62-99] 62
- Temp (24hrs), Avg:98.2 °F, Min:97.7 °F, Max:98.6 °F
- Respiratory Rate: [18-20] 18
- SpO2: 98 % O2 Delivery Method: None (Room air)
- Height: 5′ 3″, 160cm
- Daily Weight: 85.7 kg (189 lb)
- BMI (Calculated): 33.49
- Pain Score: 0
No results for the last 24 hours
Mental Status Examination: A.B is 30-year-old and 18week pregnant female who looks as stated. She appropriately dressed, neat and casual in attire.She maintains fair eye contact, calm and cooperative. Her speech is normal volume, rate an without latency. There is no. There is no indication of psychomotor agitation or retardation. She indicates her mood has improved but she feels depressed. Affect is restricted. She is awake and orientated to person, place and time. Her thought process is concrete. She reports AH with no indication of SI, HI, or VH. Insight and judgement are limited but improving
- Severe bipolar I disorder, most recent episode mixed, with psychotic features (HCC)
- 18 weeks’ gestation of pregnancy
The patient has a history of bipolar 1 consistent with American Psychiatric Association (2013) DSM-5.
Reflections: Will change to one-to-one monitoring for suicidal and aggressive behaviors. Will continue trial of Zyprexa at current dose as patient does show some evidence of overall improvement compared to last week. Will also check EEG to rule out delirium as patient is noted to some fluctuations in mentation over the course of the day.
Case Formulation and Treatment Plan:
Current suicide risk level:
- Most recent PHQ-9 Question 9 Score = 0
- Imminent risk of suicide or self-harm in the hospital is currently: Moderate
- Imminent risk of suicide or self-harm if discharged to outpatient care is currently high
Current aggression risk level:
· Imminent risk of danger to others in the hospital is currently: Moderate
· Imminent risk of danger to others if discharged to outpatient care is currently:High
Restrictions: Restrict to unit
Precautions: One-to-one monitoring for suicidal and self-harm behaviors – patient is at high risk of self-harm or suicide as an inpatient and one-to-one monitoring for aggression. Patient is high risk of danger to others as an inpatient
- OLANZapine zydis, 10 mg, oral, Nightly
- OLANZapine zydis, 5 mg, oral, QAM (Stahl, 2017)
- Prenatal multivitamin, 1 tablet, PO, Daily
- Sleep – Benadryl 50 mg po QHS PRN
- Psychotherapy – Milieu and group therapy.
- Pregnancy- 18 weeks pregnant
- Routine PRN’s provided for indigestion, pain and fever.
- Consults – Psych OT
4) Substance use: No known issues
5) Social: SW consult for aftercare planning. Increase collateral once patient consents and offer family meeting. Anticipate discharge to home pending further stabilization.
6) Education: Patient educated on working diagnosis, risks and benefits of above medications including off-label uses, treatment options including risks of inpatient verses outpatient care, alternative therapies and no treatment.
LOS: 5 days
Estimated LOS: 7-10 Days
Reason for Continued Stay: Acute Psychosis and poses a danger to self and others
Barrier to discharge: Psychiatrically unstable
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Stahl, S. M. (2017). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (6th Ed). Cambridge University Press
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