SBAR

A 28-year-old male with schizophrenia was brought to the ER due to aggressive behavior. He had stopped taking his medication and had a history of depressive episodes. He showed symptoms of paranoia, hallucinations, and agitation. After receiving treatment with olanzapine and venaflexine, his condition improved. He will be transitioning to a day program and follow up in two weeks. His vital signs are stable and he is ready for discharge, although his mother still has concerns. The mother and the patient were educated on the diagnosis, medication, and resources for further support. Good morning, Dr. Lucas. This is Alexis Spikes, RN. I'm calling that patient David Carter, a 28 year old male Caucasian. He was brought into the ER department nine days ago with some aggressive behavior. He was brought in by the police department. The patient was diagnosed with schizophrenia 10 years ago. He was brought in because he actually threw a chair at his mother. The mother stated that he had stopped taking his medication recently due to a 20-pound weight gain. He also had a history of a depressive episode five years ago in which he was treated with Haldol that had an adverse reaction and was successfully treated with venaflexine. Sorry, I can't pronounce it correctly. During his initial assessment, he was isolated, paranoia, and had some hallucinations. He was very withdrawn and agitated and had a high risk for violence. He had poor personal hygiene upon assessment and he also refused to eat. At that time, the physician, Dr. Mishra, ordered a dietary consult and a 2,100 calorie diet restriction. Over the past nine days, he has improved. He has been treated with a combination of olanzapine and venaflexine, 75 milligrams. Olanzapine is 10 milligrams. He has participated in his groups. He has a decline in the paranoia. He still has some delusions, however, they're not as frequent as they primarily were. His AIM score was a 2. He is scheduled to DC tomorrow and at that point, he is supposed to follow up in two weeks, but he is going to be going to a partial hospitalization day program. He has to check with a social worker about acceptance and go from there. He was going to follow up and follow up, two week follow-up appointment. He's going to transition to the Amirzapol 9 month, sorry, monthly injection. Current vital signs were temp was 99, pulse was 90, respiration 16, blood pressure 134 over 84. He did not have any kind of pain at this time. He is alert and oriented times three. He does seem a little bit still agitated, but not as excessive as it was initially. His O2 is 96 on room air. Clear lung sounds, no edema noted, and there's no tenderness or dissension to his abdomen. He denies any nausea, vomiting. His urine is yellow and clear in color. He is able to move all extremities. His skin is warm and dry and no wounds noted. We've not received any abnormal testing results on him. I think at this time he is good to discharge and with the exception of the day program and the following up with the two-week appointment, the mother did have still some concerns and worries about him going home with some fear. I educated the mother and the son on the diagnosis, the medication, and the discharge planning, and then also resources were provided for any extra help, and they were also educated on to return to the ER if the symptoms persist. Okay, yes sir, he is good to go and we have him scheduled to discharge tomorrow. Thank you.