Case Note Record of Key Worker Session Essay Example | Topics and Well Written Essays - 1000 words

Case Note Record of Key Worker Session - Essay eccentricWhen I inquired approximately the reason of his insomnia, he informed me that he had been undergoing a lot of stress for the prehistoric 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 stimulate abusive, if he does not provide adequately. This has been constant practise for the past 2 months. Since he has high obeisance 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 mothers 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 mothers house. He expressed his hope to buy a house for and live there by himself. He himself suggested th at it would be a huge way to address his insomnia and bipolar disorder that he had been admitted for. Mr. make said that he would often break away to his friends apartment for a few days to clear his mind, when things got worse with his mother. Clearly, one of the reasons for Mr. Coopers insomnia and conformations of economic crisis 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. Coopers condition, and prompt challenge should be taken, before his discharge, which is scheduled on the 3rd of December. Sincerely, Head nurse, Department of Psychiatry Discharge abridgment Patients name Dennis Cooper Age 45 years Condition bipolar disorder Discharge while 1245 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 4p m, 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 long hundred/80. On awakening, the patient started talking incessantly, smiling constantly and seemed very excited and elated. This lasted for approximately 3 hours, later which he fell asleep. After awakening from a 6-hour nap, the patient had a severe headache, which subsided after disposal 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 observe during the course of his stay. The patient was under moderate sedation and antidepressants throughout his stay at the center, and this combination was accommodating in maintaining a neutral state of mind, without any agitati on 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 needfully 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