mdcall

Alexis Spikes, an LVN from Harbor Hospital, calls Dr. Parr regarding patient Sharon Cole. Sharon has a history of bipolar disorder and was admitted with a fractured ankle. She has not been compliant with her medication and had a previous noncompliance-related episode two years ago. She is currently being treated with lithium. Her vital signs are stable, but she shows signs of confusion and agitation. Alexis suspects that Sharon may be experiencing another manic state and requests a SAT consult. The plan of care includes monitoring vital signs, increasing Ativan dosage, and notifying Dr. Parr of any changes. Good afternoon, Dr. Parr. This is Alexis Spikes, LVN. I'm calling from Harbor Hospital in regards to a patient, Sharon Cole. Date of birth is 3-15-92. I'm calling and my main concern with her is her mental health. She was admitted last night by Dr. Johnson with a fracture of her ankle. Patient also has a history of bipolar. She was diagnosed six years ago. It's currently being controlled with lithium 600 milligrams BID. The patient's spouse also reports that she has not been compliant with her medication. Her last medic episode was about two years ago, which was also a result of noncompliance. She is the full code. She has no allergies. Her vital signs are 99 temp, 88 pulse, 16 respiration, 134 over 70 for BP. The patient is currently denying pain. However, she is being medicated with a fentanyl pump for pain for the fracture. She is currently taking Ativan, one milligram PRN for agitation. And she also was ordered vancomycin, one gram for two doses. She does have an IV. During the assessment, she really had pressured speech. She had some agitation. She was alerted to orientative times two with some confusion. She could not remember what happened the previous night, how she ended up with the fracture, so forth, so forth. She was also very hard to redirect and reorient. She was just making statements about Washington and she needed to get back to work, things like that. Respiratory wise, she denied any difficulty breathing. Her O2 sat was 100% on room air. Her lung sounds were clear in all fields. Patient also denied chest pain. She had no edema in her upper or lower extremities. No tenderness to her abdomen. All bowel sounds were active. Her skin was moist and I did not see any open areas or wounds except for the surgical incision for the fracture, which she underwent surgery this morning at 0800 and I've not seen any complications with that surgery. Her current lithium level is 0.2. With this patient, my main concern and my problem, the problem I think that she may be having is neurological. I really do believe that she's possibly in another manic state. I'm just asking, I would be asking if we could go ahead and do the SAT consult. I believe this would be the proper thing to do as far as her situation now just based off of my assessment. So at this point, what is the current plan of care that we need to continue on or do you have any new orders for me? Okay, so let me just read these back to you to make sure I have everything correct. So you want me to go ahead and do the SAT consult for today and depending on what the psychiatrist recommends, she could possibly discharge in the morning and then we'll increase her vital signs to Q4 hours and also increase the Ativan to two milligrams Q4 PRN agitation and then you just want to be notified if her health declines or if her mental state worsens. All right, I have those orders, I'll go and put in and we'll notify you if anything changes. Thank you, have a good evening.