Resident Physician: Kenneth Acha, MD, UCR FM PGY2
Attending Physician:
Consulting Physician:
Reason for care: Medication management / Psychotherapy / 5150
Discussed & Coordinated Care with:
CC & HPI / INTERIM HISTORY
DATE LAST SEEN:
SINCE LAST SEEN:
Improved / Worsened / Stable with no new problems.
VITAL SIGNS:
MENTAL STATUS EXAM
GENERAL APPEARANCE: Appropriate, stated age. Not Younger / Older / Disheveled / Under weight / Over weight / Withdrawn / Preoccupied
BEHAVIOR: Appropriate, Cooperative. Not Agitated / Hostile / Uncooperative / Slowed
SPEECH: Normal and clear. Not Pressured / Loud / Soft / Slowed / Aphasic / Fluent / Nonfluent / Indistinct
MOOD/AFFECT: Appropriate to situation. Not Sad / Anxious / Apathetic / Worried / Angry / Labile / Blunted / Happy
THOUGH PROCESS: Normal, Logical. Not Loose / Obsessive / Preoccupied / Disorganized / Personalized / Circumstantial / Tangential / Blocking / Somatic
HALLUCINATIONS: No auditory or visual hallucinations.
DELUSIONS: None. No Guilt / Grandiose / Somatic delusions.
SUICIDAL: No & No Plan.
HOMICIDAL: No & No Plan.
ORIENTATION: X3. Not disoriented.
ATTENTION: Alert. Not lethargic.
CONCENTRATION: Intact. Not impaired. Not confused.
FUND OF KNOWLEDGE: Average. Not Superior / Impaired / Poor.
MEMORY: Intact. Not Impaired / Selective / Poor / Immediate / Recent / Past / Remote
ABSTRACT REASONING: Intact. Not Impaired / Poor
JUDGMENT: Good. As opposed to Fair / Poor.
INSIGHT: Fair. As opposed to Good or Poor.
INTELLIGENCE: Average. As opposed to High / Low / MR
GAIT: Stable. Not Ataxic / Unsteady / Shuffling/ Impaired. Not in WC. Doesn’t Use walker. Normal muscle tone/strength.
CURRENT CONDITION: Improving
LABS:
IMAGING:
SIDE EFFECTS: None. No EPS, Sedation, Constipation.
TARDIVE DYSKINESIA: No
DIAGNOSES
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PROGNOSIS: Fair
ASSESSMENT: Symptomatically prognosis is: good / poor / guarded / improving / unchanged / worse / other______
MEDICATIONS: Effective / Ineffective / Partially effective / tolerating well _________________
TREATMENT PLAN:
Adjust medications / Continue current approach.
Social services consult to corroborate his story. Also, assess the patient for disposition either to Michigan or to an alcohol rehab center.
Continue Ativan for a total of five days since admission and then taper off.
No Librium secondary to liver problems.
Start Celexa 10mg
Increase dose of Trazodone to 50mg
DECISION MAKING: Minimal / Moderate / Complex
RISKS OF COMPLICATIONS, MORBIDITY, AND MORTALITY: None / limited / moderate / severe.
MEDICATIONS REVIEWED / ADJUSTED:
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These psychotropic medications have been reviewed for decrease or D/C:
These psychotropic medications are at maintenance doses and will be continued as prescribed:
Treatment modalities risks and benefits discussed. Patient understands and consents to treatment.