Mental Health Case Summary

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A review of her medical records indicates that she was hospitalized on 1/26/17 to 2/3/17 for fever which was suspected to be neurogenic in nature. Late last year she suffered anoxic encephalopathy post cardiac arrest which resulted from heroin abuse. As a result of her brain injury she is aphasic with contracted limbs. She is bedbound. she suffers from chronic tachycardia, chronic muscle spasm and amenorrhea.

At today's visit she is accompanied by her mother. She is found lying in her hospital bed on her back. She is awake, nonverbal and unable to follow commands. Her mother reports that she has chronic generalized pain, which exhibits itself by her grimacing and moaning. She is unable to describe or rate her pain. The mother states

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