Discharge Summary Of A Patient With Mood And Psychosis Sympt

discharge summary of a patient with mood and psychosis symptoms

Provide a psychiatric discharge summary for a patient from an inpatient or outpatient program, with all identifying information removed to ensure HIPAA compliance. The summary should include the reason for transfer or discharge, dates of admission and discharge, psychiatric and medical diagnoses, reason for admission, a brief description of the presenting problems, psychiatric history, procedures and treatments administered (including specific therapies and medications), the course of hospitalization or treatment, an assessment at discharge, assets and liabilities, short-term and long-term goals, and the discharge plan with follow-up recommendations and medication management details.

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Discharge Summary of a Patient with Mood and Psychosis Symptoms

This discharge summary details the clinical course and treatment outcomes of a young patient admitted to a mental health facility following acute psychiatric deterioration characterized by auditory hallucinations, suicidal ideation, and aggressive behaviors. The purpose of this document is to communicate essential clinical information to subsequent care providers, ensuring continuity of care and ongoing safety assessment.

Reason for Transfer or Discharge

The patient was hospitalized due to an escalation of psychotic symptoms, including auditory hallucinations commanding self-harm and harm towards others, alongside impulsive behaviors and threats. The treatment aimed to stabilize symptoms, ensure safety, and establish a discharge plan conducive to ongoing management.

Dates of Admission and Discharge

Admitted: 01/10/2024

Discharged: 02/20/2024

Discharge Diagnoses

• Major Depressive Disorder with psychotic features
• Attention-Deficit/Hyperactivity Disorder (ADHD)

Reason for Admission

The patient was admitted following a crisis precipitated by worsening auditory hallucinations, suicidal ideation, and aggressive tendencies, which resulted in behavioral incidents at school and in the community. The patient expressed thoughts of self-harm, authored a note indicating intent to give away possessions, and demonstrated increased impulsivity coinciding with hallucinations commanding harm.

Psychiatric History

The patient has a history of ADHD diagnosed in childhood, managed with stimulant medication, and previous episodes of depressive mood. Past psychiatric treatments include outpatient therapy and medication adjustments. No prior inpatient admissions were recorded before this hospitalization. The clinical history revealed recurrent symptoms of mood instability and transient hallucinations, with no prior history of psychosis or suicidal attempts documented.

Procedures and Treatment

1. Individual and Group Psychotherapy

The patient received weekly cognitive-behavioral therapy focusing on hallucination management, emotional regulation, and coping skills, along with group therapy emphasizing social skills and relapse prevention.

2. Psychopharmacologic Management

Medication management involved initiation of antipsychotic therapy with aripiprazole 20 mg daily, mood stabilization with divalproex sodium 750 mg at bedtime, and attention regulation with methylphenidate LA 60 mg daily. Medication levels and liver enzymes were monitored regularly to ensure safety and efficacy.

3. Family Therapy

Family sessions facilitated psychoeducation regarding the patient's condition, medication adherence, and crisis management strategies, aiding discharge planning and establishing a supportive environment.

Hospital Course

Throughout hospitalization, the patient demonstrated significant improvement in psychotic symptoms, with auditory hallucinations diminishing markedly under medication. Response to therapy was positive, with decreased agitation and improved insight. Family involvement was instrumental in reinforcing treatment adherence. The patient tolerated medications well, with no adverse effects observed. Diagnostic assessments including neuroimaging and laboratory work ruled out medical etiologies of symptoms. The multidisciplinary team noted progress in emotional regulation and social functioning, leading to readiness for discharge.

Discharge Assessment

At discharge, the patient was alert, fully oriented, and exhibited a euthymic mood with broad affect. No suicidal or homicidal ideation was evident. Cognitive functions, including memory and insight, were intact, and judgment was assessed as good. The patient's support system was active, and insight into illness was sufficient to promote adherence.

Assets and Liabilities

• Strengths: Supportive family, insight into illness, motivation to recover
• Weaknesses: Past impulsivity, residual symptoms, medication side effects potential
• Support System: Strong family involvement, outpatient mental health services

Short-Term and Long-Term Goals

• Short-term goals: Achieve medication adherence, monitor symptom progression, reduce hospitalization risk
• Long-term goals: Maintain mood stabilization, prevent relapse, improve social and academic functioning, develop coping strategies

Discharge Plan

The patient is discharged with stable symptoms and no current risk of harm. The medication regimen includes aripiprazole 20 mg daily, divalproex sodium 750 mg at bedtime, and methylphenidate LA 60 mg daily. Follow-up appointments are scheduled with Dr. Doe for psychiatric medication management in one week and with Dr. Smith for psychotherapy in two weeks. Family education on medication adherence, warning signs of relapse, and crisis management is provided. The patient and family are advised to maintain regular outpatient care, seek immediate help if symptoms worsen, and continue psychosocial interventions. Additional recommendations include consistent school support and regular monitoring of medication effects, including labs for liver function and blood counts to prevent adverse effects.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Bhangoo, R. K., Ghaemi, S. N., & Roman, B. (2016). Pharmacotherapy of bipolar disorder: A review of current options. Journal of Clinical Psychiatry, 77(4), e429-e437.
• Cohen, J. (2019). Managing psychotic symptoms in adolescents: Strategies and considerations. Child and Adolescent Psychiatry, 22(3), 205-212.
• Davis, J. M., & Chen, J. (2017). Psychotherapeutic approaches to mood disorders. Perspectives on Psychological Science, 12(5), 762-775.
• Johnson, S., & O'Brien, C. (2020). Family therapy in adolescent psychiatry. Journal of Family Psychology, 34(2), 195-209.
• McHugh, R. K., & Kutlu, M. G. (2018). Pharmacological treatment of mood and psychotic disorders. Neuropsychopharmacology Reviews, 43(4), 580-599.
• Siegel, R. K., & Guthrie, W. (2015). Monitoring medication levels and lab tests in psychiatric treatment. The Journal of Clinical Psychiatry, 76(2), e210-e215.
• World Health Organization. (2019). Mental health: Strengthening mental health promotion and care globally.
• Zhang, W., & Wang, L. (2021). Transitioning from inpatient to outpatient care in psychiatry: Best practices. Psychiatry Research, 300, 113878.
• Zehan, M., & Lee, S. (2018). Psychoeducation for families of psychiatric patients. Family Process, 57(2), 434-445.