CHIEF COMPLAINT: Fever, chills PRESENT ILLNESS: Patient is an 82-year-old

inley Jennifer is a 40 y/o Caucasian female who was admitted to the ward 302 five months ago for continuation of care. The patient remained alert and oriented X 3. She is calm and ambulates in the ward with a steady gait. The patient denies pain or discomfort at this time. She does not appear in any distress. The patient has been cooperative and compliant with her prescribed medication but sometimes refused her stool bisacodyl The patient denies A/V/T hallucination. As mentioned above the patient has been engaged in inappropriate sexual behavior and assaultive behavior for this review period., . Her mood and affect are full and congruent. Her thought process is logical , no perceptual disturbances.. Ms. Finley’s memory is good, and her cognition level is average. She has good judgment but she has no insight into her mental illness. She denies changes in her appetite and sleep pattern. As per documentation, the patient is losing weight but has no sleep; disturbance reported; she sleeps well at night for 6 to 8 hours at night time. Her ADLs are fair and performed independently. We will continue to monitor and assess the patient while the staff maintains safety and a therapeutic environment.

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