Schizophrenia Discharge Summary Transcription Sample Report
DISCHARGE DIAGNOSES:
AXIS I: Schizophrenia, paranoid type; polysubstance abuse, alcohol and crack, currently in remission.
AXIS II: Deferred.
AXIS III: New-onset diabetes type 2.
AXIS IV: Financial stress, unemployment, currently in rehab, chronic mental illness.
AXIS V: Global assessment of functioning on admission 25. Global assessment of functioning on discharge 50.
PROCEDURES PERFORMED: MRI of the head was performed with and without contrast. It showed prominent nasopharyngeal tissue with internal cysts, more prominent on the left, and probable prominent adenoidal tissue, including Tornwaldt cyst, a slightly tortuous left vertebral artery minimally indented in the left medulla and minimal prominence of the right temporal horn when compared to the left, which is most likely a normal variation. Otherwise, normal brain MRI.
CONSULTANTS:
1. Physical therapy.
2. ENT.
3. Endocrinology.
ALLERGIES: No known drug allergies.
DISCHARGE MEDICATIONS:
1. Wellbutrin 100 mg p.o. b.i.d.
2. Metformin 500 mg p.o. b.i.d.
3. Risperdal 3 mg p.o. b.i.d.
4. Trazodone 200 mg p.o. at bedtime.
5. Naprosyn 500 mg p.o. b.i.d. p.r.n. for pain or headache.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a history of schizophrenia and polysubstance abuse referred by his case manager due to increased hallucinations, including auditory, and new onset of olfactory, gustatory and tactile hallucinations. Since the onset of the hallucinations, the patient has become acutely suicidal with multiple plans. He has a history of polysubstance abuse with alcohol and crack but has been sober for greater than 3 months and has been in rehab. He also complains of headaches recently. The patient, with history of schizophrenia, presented frightened, tearful and continued to endorse suicidal thoughts.
PAST PSYCHIATRIC HISTORY: Paranoid schizophrenia, substance abuse.
PAST MEDICAL HISTORY: Left shoulder injury with chronic pain and a seizure one time in the past.
FAMILY HISTORY: The patient does have a brother with schizophrenia and a mother who died from complications of diabetes.
SOCIAL HISTORY: The patient currently is in rehab. Divorced. Did finish high school and went to junior college for a little while but did not get a degree. He has been unable to hold a steady job for most of his life.
REVIEW OF SYSTEMS: Included headache and some blurry vision. He denies constitutional symptoms. He denied chest pain, difficulty breathing, GI symptoms, dysuria. He does endorse left shoulder pain. He denied any skin conditions and he does endorse numbness of his distal feet.
MENTAL STATUS EXAMINATION: Appearance and Behavior: He had good eye contact, well groomed, fair hygiene. Speech and Language: Normal volume, tone and rate, nonpressured. Mood and Affect: Mood was depressed and affect was congruent and restricted. Thought processes linear and goal directed. Though Content: He does have some paranoia believing that people, including the doctors, are experimenting on him. HI/SI: He denies currently having suicidal ideations. Perceptual Abnormalities: He reports visual, auditory, gustatory and tactile hallucinations. Orientation: He is alert and oriented x3. Memory and abstractions are fair. Fund of knowledge and IQ are average and insight and judgment are limited and poor. His initial physical exam was significant for pain and decreased range of motion in the left shoulder on passive abduction and extension and a mild paresthesia of the plantar surface of his right second toe; otherwise, neurologic exam was normal.
LABORATORY DATA: Initial labs included a CBC, which was within normal limits. Electrolyte panel showed sodium of 133, potassium of 4.1, chloride 100, bicarb 27, BUN 13, creatinine 1.1 and a random glucose of 291 with calcium of 9. LFTs were within normal limits. Total cholesterol was 145, HDL 44, LDL 92, triglycerides 49. TSH within normal limits.
HOSPITAL COURSE:
1. The patient was evaluated and treated by the multidisciplinary treatment team including physicians, nurses, social workers and therapists. All medications were presented to the patient and he gave written consent to all the medications he was given, as well as was explained the risks, benefits, side effects and alternatives of all medication therapies. The patient was integrated in some milieu on the ward and encouraged to attend to his ADLs and participate in groups.
2. Schizophrenia: On admission, the patient’s Risperdal was gradually titrated up to a goal dose of 3 mg twice a day prior to discharge. He tolerated the medication well with no significant side effects and reported that his hallucinations significantly improved. He denied psych symptoms prior to discharge. The patient presented as very organized in his thoughts, linear, logical and appropriate. He did not have any behavioral or management problems while in the unit and participated in groups very well with good interactions with staff and peers, as there has been some question whether the patient also has a mood component of his psychiatric disease. His trazodone was increased to 200 mg at bedtime to help with sleep and his Wellbutrin was maintained at his home dose. His mood improved throughout hospitalization as well, and he was euthymic with appropriate affect prior to discharge. The patient did have neuro psych testing done while in the hospital. Results are pending at the time of discharge.
3. Diabetes: The patient was diagnosed with new onset of diabetes during this hospitalization. A hemoglobin A1c was sent, which came back elevated at 8.7. He also had a fasting glucose done, which was elevated at 216. Given that the patient met criteria for diabetes, endocrine was consulted and agreed with the plan to start patient on a low dose of metformin and titrate it up to a goal of 500 mg twice a day prior to discharge. The patient tolerated the metformin well and his blood sugars came under good control. His blood glucoses prior to discharge were 98 and 106 respectively. He was maintained on a sliding scale insulin as needed for increased blood sugars; however, the glucose seemed to be well controlled with just the oral hypoglycemic agent. The patient’s headaches also seemed to resolve once he was well hydrated and his blood sugars were under control. He will follow up with the endocrine clinic in 2 to 3 weeks for management of his diabetes and outpatient referral form was faxed and the patient was instructed to follow up with an appointment.
4. Shoulder pain: The patient has had left shoulder pain, which appears to be a frozen shoulder versus a rotator cuff tendinitis. We continued him on Naprosyn as needed for shoulder pain. We also consulted physical therapy, who were able to provide him with several exercises to improve his range of motion and pain in his shoulder. The patient was very agreeable with completing the exercises and claims to continue doing them as an outpatient.
5. Nasal cyst: An incidental finding on MRI was Tornwaldt cysts. ENT was consulted and recommended that he follow up as an outpatient as these are usually benign and most likely just an incidental finding and do not have any pathological significance. He should follow up if he has any further questions or concerns.
6. Disposition: The patient was initially on a 72-hour hold and was able to sign in voluntarily to the hospital. He was provided with diabetes education prior to discharge and he was to go back to rehab until he completes the program there.
DISCHARGE CONDITION: Good.
DISCHARGE INSTRUCTIONS:
1. Diet: ADA diabetic diet.
2. Activity: Ad lib with continuing of the exercises for his left shoulder.
3. Take medications as prescribed and not making any changes without first consulting with his outpatient doctor.
4. He was advised to avoid substances as he has been sober now for greater than 3 months.
5. He should follow up with endocrine clinic.
