| Padilla, Manuel |
| MRN: 126318 | Room: 173 | DOB: 7/18/1990 | Age: 35 | Gender: Male | Allergies: Penicillin (hives) |
| Setting | Adult Psychiatric Unit | ||
| Scenario | This morning when you see the patient on rounds at 8:30, MP continues to express paranoia that the FBI is poisoning his food and the food of others around him, as well as disorganized speech. He now states that he hears voices telling him to stab himself with a knife. He states that he does not want to harm himself but he is getting tired of the voices telling him what to do and he “doesn’t know what else to do.” When questioned further, he also admits to feeling hopeless and sad, having difficulty sleeping for the past month and experiencing a decrease in his appetite and energy level. At this point, MP’s agitation has improved and he is out of seclusion. You and the rest of the treatment team are seeing him for the first time this morning. The psychiatrist would like you to make recommendations for all of MP’s psychiatric and medical conditions. |
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| Admission note taken on 10/19/25 | |||
| CC | “The voices are telling me to stab myself. I don’t want to do it, but I am afraid that I will because I just want them to go away.” | ||
| HPI | MP was brought in to the psychiatric ER by police (last evening) at 9:37 pm after he was found acting bizarrely in a McDonald’s. The manager had called police, complaining that MP was taking food off of customers’ trays and throwing it out, as well as verbally threatening some of the customers. Upon presentation to the ER, MP presented as paranoid and agitated. He attempted to assault one of the nursing staff. At that time he was given lorazepam 2 mg IM and haloperidol 5 mg IM to which he responded well. He was placed in seclusion and remained calm overnight although he continued to exhibit paranoia and disorganized speech. He was given one dose of quetiapine 300 mg extended release PO at midnight. All other medications were held until he could be evaluated by the treatment team. |
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| PMH | Past Medical history
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam | Review of Systems
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| Test Name | 10/19/25 | 04/22/25 | Range |
| Sodium (Na+) | 141 | 143 | 136-145 mEq/L |
| Potassium (K+) | 3.2 | 3.7 | 3.5-5 mEq/L |
| Chloride (Cl-) | 110 | 107 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 26 | 28 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 12 | 14 | 8-20 mg/dL |
| Creatinine | 1.12 | 1.0 | 0.5-1.3 mg/dL |
| Glucose | 122 | 119 | 70-115 mg/dL |
| Hemoglobin A1c | 6.1 | 6.2 | 5.3-7.5 % |
| Calcium,Total | 9.4 | 9.2 | 8.6-10.2 mg/dL |
| Phosphate | 3.2 | 3.3 | 3-4.5 mg/dL |
| Magnesium | 2.1 | 2.2 | 1.6-2.6 mEq/L |
| Protein, total | 6.2 | 6.4 | 5.5-9 g/dL |
| Albumin | 4.6 | 4.9 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 23 | 25 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 34 | 13 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 97 | 101 | 80-225 units/L |
| Alkaline phosphatase | 45 | 42 | 30-120 units/L |
| Bilirubin, Total | 0.7 | 0.6 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 10.8 | 9.5 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 5.07 | 4.62 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 15.4 | 14.3 | 14-18 g/dL |
| Hematocrit, Male | 33.8 | 41.9 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 30.3 | 31.0 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 89.6 | 90.7 | 76-100 mcm3 |
| Platelets | 273 | 299 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.1 | 1.0 | 0.8-1.2 |
| Prothrombin time (PT) | 10.2 | 10.1 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 29 | 27 | 25-35 sec |
| Additional Labs: |
Fasting Lipid Panel
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| Cultures: |
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| Imaging Studies: |
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| Medication History |
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| Patient Name: Padilla, Manuel Date of Birth: 7/18/1990 Room#: 173 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/19/25 |
| Quetiapine 300 mg Extended-Release PO x1 dose | 00:17 |
| Lorazepam 2 mg IM Q4H PRN PRN agitation | |
| Haloperidol 5 mg IM Q8H PRN PRN paranoia or agitation |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Patient Name: | ||
| Admission Date: | Discharge Date: | Service: |
| Principle Diagnosis on Admission: | ||
| Secondary Diagnosis: | ||
| Allergies: | ||
| Medications ADDED this visit: (begin taking these) |
Medications CHANGED this visit: (modify what you were taking) |
Medications STOPPED this visit: (stop taking these) |
| Final Discharge Medication List | |||||
| Medication/Route/Dosage/Frequency/Duration | Comments | Morning | Afternoon | Evening | Bedtime |
| As Needed Medications | |||||
| Patient Name: Padilla, Manuel | Date of Birth: 7/18/1990 | Room: 173 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |