Patient is a white female admitted with Mood Disorder NOS and R/O Bipolar Disorder. She has a strong family history—mother is positive for Bipolar Disorder and Anxiety Disorder and has attempted suicide 3X since January. Her uncle is positive for Personality Disorder. Patient was raped at her stepfather, sexually abused by her Grandfather whom she resides, and physically abused by her biological father whom she resided with for 6 months, prior to moving in with her Grandparents. Patient was arrested on domestic violence charges after attacking her Grandmother immediately prior to admission to facility.
Axis I Mood DO NOS & R/O Bipolar DO
Axis II Deferred
Axis III sinus/allergy exacerbations; GERD
Axis IV Severe—Stressors>Grandparents custody; Mothers’ mental illness; abuse
Patient has a court hearing for November 5th for possible foster placement. DHR is currently working with social workers to arrange placement upon discharge. Patient has very little support system, and will need a caregiver until she is no longer a minor.
Upon discharge, custody will be given to New York's DHR services and placed in a foster home. Patient has been abused in each caregiver’s home that she resided in; therefore, placement with family will not be possible. Hearing to occur on November 5th of this year.
Currently, support system consists of Guardian at Latium, Therapists, Social worker and staff at hospital. Patient does not wish to release any information regarding treatment or placement to Grandparents, parents or sibling. She wishes for all of this to remain confidential.
Nexium20mg BIDProton pump inhibitor; indicated for GERD
Adverse reactions include diarrhea, headache, nausea,
Vomiting, flatulence, abdominal pain, constipation
And dry mouth. Take exactly as prescribed; do not double
Dose if dosage missed. Take at next...