Discharge summary peer review

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Please both attachments one is including the instructions and the other the peer review writting.

REASON FOR TRANSFER SUMMARY:  

· This is a transfer summary on Mr. K as the patient will be leaving today and will be transitioned into the care of his brother following successful treatment of his Post-Traumatic Stress Disorder (PTSD).

DATE OF ADMISSION: 

· 04/05/2018 

DATE OF DISCHARGE:  

· 08/19/2018

DISCHARGE DIAGNOSES:  

· Treatment and maintenance of PTSD as well as observation in an outpatient setting.

· F43.1 Post-Traumatic Stress Disorder

REASON FOR ADMISSION:  

· The patient was brought into the emergency room by his brother with a chief complaint of intrusive thoughts throughout the day and nightmares at night. The patient was admitted to psychiatric care after making attempts to fight his brother in his exhausted daze causing minor injuries. Before this, the patient began to become more reclusive and began to eat less following the death of his father in an animal attack. Patient denied SI/HI. Patient denies hallucinations. No delusions observed,

PSYCHIATRIC HISTORY: 

· Before the incident, the patient presented with no past psychiatric hospitalizations or any other procedures having to do with mental disorders.

PROCEDURES AND TREATMENT: 

1. The patient was referred to a therapist specializing in cognitive-behavioral therapy (CBT) which he so attended for one hour, twice a week, for three months. The patient obliged and followed his scheduled sessions rigorously

2. The patient was prescribed Sertraline (Zoloft) for the maintenance of his PTSD.

3. Patient is prescribed Prazosin (Minipress) for nightmares.

HOSPITAL COURSE: 

· The patient was admitted on 04/05/2018. Upon admission, Mr. K appeared disheveled, malnourished, irritable, easily agitated, and lethargic. Patient reports intrusive thoughts, insomnia, poor appetite, and reoccurring nightmares. Patient was upset during the admission process and received oral medication. The patient spent several months diligently following his nutritional, medication, and therapy schedules until 08/19/2018 when he was deemed safe for outpatient care.

DISCHARGE ASSESSMENT:  

· The patient is alert and oriented x4 to person, place, time/date and situation at the time of discharge. Patient contracted for safety and agreed to follow safety plan if intrusive thoughts reoccur. Patient agreed to continue medications as prescribed, attend CBT therapy sessions, and have follow up appointments with provider. 

ASSETS and LIABILITIES:
 
  

Assets:

· A supportive and loving family

· Currently under mental health treatment

· Currently receiving pharmacological treatment

Liabilities:

· Insomnia 

· Lack of coping mechanisms

Short-term goal:

· Identify symptoms that patient is experiencing PTSD

· Identify triggers that caused PTSD symptoms

· Continued participation in CBT sessions

· Follow medication schedule.

Long-term goals:

· Continue maintenance medications as prescribed and therapy

· To build a mental stability

· Manage PTSD symptoms in an appropriate manger

DISCHARGE PLAN: 

· Patient is to continue to take his medications at the prescribed dosage.

· Continue Sertraline (Zoloft) 100 mg Po Daily. It is advised to wait a few weeks to increase to the next dosage or speak to provider regarding increase. Maximum dose is generally 200 mg/day in a single dose.

· Continue Prazosin (Minipress) 5 mg Po BID.

· Continue to follow the bi-weekly scheduled CBT sessions.

· Scheduled checkups on a weekly basis.

Thank you for receiving this summary.

Signature: Leslie De Vera, PMHNP Student

Respond to peers with the following: Read another student’s progress note and assume that you are a PMHNP who will see this patient in an outpatient practice for follow up. Is there anything that wasn’t clear in the note that you would like to ask your NP colleague? Also, assume the patient isn’t tolerating the medication when you see them in follow up. Identify an alternative medication that would be appropriate and why you would choose it. Please support your writing with at least one peer review journal.

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