Date: 05/10/2020 Student Name: Assigned vSim: Sandra Littlefield
Initials: SL Diagnosis: HCP: Dr. Smiley Isolation: N/A IV Type: N/A Critical Labs: Other Services:
Borderline N/A N/A
personality
Age: 36 yrs old disorder
Risk for self-
directed violence
M/F: F
Fall Risk: N/A Location: N/A
Consults: N/A Consults
Code Status: Needed:
Full Code Group therapy
Counseling
Length of Stay: Transfer: N/A
Pt is currently Fluid/Rate: N/A
incarcerated
Allergies:
Penicillin &
Codeine
Why is your patient in the hospital (Answer in your own words and include the History of present Illness):
Patient is a 36yr old female who was brought in with complaints of severe back pain and stating current medication is not helping.
GEANA
, Health History/Comorbities (that relate to this hospitalization):
Sandra has a diagnosis of borderline personality disorder. She has been compliant during this incarceration but has a history of aggressive behavior during
past incarcerations. She has a history of sex abuse and has been hospitalized for suicide attempts in the past, as well as for drug and alcohol problems.
She does, as mentioned, also have a history of back pain with frequent emergency room visits. During her prior two visits to the nurse, she was given
acetaminophen and ibuprofen for pain, but she is now demanding “something stronger” for the pain.
Initials: SL Diagnosis: HCP: Dr. Smiley Isolation: N/A IV Type: N/A Critical Labs: Other Services:
Borderline N/A N/A
personality
Age: 36 yrs old disorder
Risk for self-
directed violence
M/F: F
Fall Risk: N/A Location: N/A
Consults: N/A Consults
Code Status: Needed:
Full Code Group therapy
Counseling
Length of Stay: Transfer: N/A
Pt is currently Fluid/Rate: N/A
incarcerated
Allergies:
Penicillin &
Codeine
Why is your patient in the hospital (Answer in your own words and include the History of present Illness):
Patient is a 36yr old female who was brought in with complaints of severe back pain and stating current medication is not helping.
GEANA
, Health History/Comorbities (that relate to this hospitalization):
Sandra has a diagnosis of borderline personality disorder. She has been compliant during this incarceration but has a history of aggressive behavior during
past incarcerations. She has a history of sex abuse and has been hospitalized for suicide attempts in the past, as well as for drug and alcohol problems.
She does, as mentioned, also have a history of back pain with frequent emergency room visits. During her prior two visits to the nurse, she was given
acetaminophen and ibuprofen for pain, but she is now demanding “something stronger” for the pain.
