MENTAL STATUS EXAMINATION: The patient’s general appearance was neat and clean. She was a willing participant in the interview. Her behavior was cooperative and free with information giving. Her eye contact was virtually constant. Her affect was depressed. Her mood is depressed and irritable. Her speech is of normal rate and tone and clearly articulated. There was no psychomotor restlessness nor retardation. She ambulates with a steady gait and a relaxed posture. Her hygiene is within normal limits. Her thoughts were spontaneous, organized, linear, and logical with no current evidence of a formal thought disorder. There were no gross or overt objective signs of psychosis. She is alert and oriented to person, place, time, and situation. Her memory is intact. Her intellectual functioning is at baseline and is average. Her insight and judgment are fair.

MENTAL STATUS EXAMINATION: The patient’s general appearance is neat and clean. He was a willing participant in the interview. His behavior was overly cooperative, charming, information giving, and extremely attentive. His eye contact was intermittent and appropriate. His affect was mood congruent and inappropriately bright at times. His mood appeared to be somewhat hypomanic. His speech was loud and in normal rate and clearly articulated. There was some psychomotor tics noted secondary to his Tourette. He ambulated with a steady gait and a relaxed posture. His hygiene was within normal limits. His thoughts were spontaneous, organized, logical, and linear. There is no current evidence of a formal thought disorder of any kind. The patient was able to stay on topic and was able to stay attentive. His thought process never became circumstantial nor tangential. There was no evidence of delusional thought process or ideas of reference. There were absolutely no gross or overt objective signs of psychosis. He is alert and oriented to person, place, time, and situation. His memory is completely intact. His intellectual functioning is at baseline and is probably above average. His insight is lacking. His judgment is questionable.

MENTAL STATUS EXAMINATION: The patient presented casually dressed and was alert and oriented to time, place, and person. Her mood was labile, and she was very agitated. She became quite loud, abusive, and was yelling and screaming. She slammed the door and left the room. She denied any auditory or visual hallucinations, as well as any suicidal or homicidal ideations at the time of the interview. Her insight and judgment were poor.

MENTAL STATUS EXAMINATION: The patient looks his stated age. Somewhat disinterested and withdrawn. Slow psychomotor. Speech was slow but coherent. Mood “down” with irritable dysphoric affect. Thoughts are goal directed, anhedonia, helplessness, fragmented sleep, low energy. No suicidal thoughts, intent or plan. No homicidal thoughts, intent or plan. No auditory, visual or tactile hallucination. No delusions of any kind. Concentration fair. Memory not formally tested. Insight and judgment adequate.

MENTAL STATUS EXAMINATION: General appearance: Acceptable motor activity, cooperative, maintained good eye contact. Fair grooming and hygiene, casually dressed. The patient had short dark hair and dark eyes. Speech and Thought Pattern: Verbal, and coherent, relevant, and spontaneous. Mood: Described as anxious. Affect: Full range. Thought Content: The patient denies hallucinations and/or delusions. Denies current suicidal, homicidal ideations. Orientation: Oriented x3. Average intellectual functioning. Fair judgment and insight.

MENTAL STATUS EXAMINATION: On examination, the patient refused to come to the interview room. He was seen in his classroom. At that time, he was being placed in a passive restraint after pushing the staff. He was crying and was quite dysphoric, and he was actually verbally threatening the staff during the interview. He refused to address the interviewer and refused to answer any direct questions. He was unable to engage in any play or joking comments, he was verbal. He was articulate particularly in talking with his staff worker. There were no extrapyramidal symptoms apparent. He did not evidence any bradykinesia or abnormal involuntary movements. He did not manifest any flight of ideas or pressured speech. He did not appear to be responding to any psychotic stimuli.

MENTAL STATUS EXAMINATION: The patient was alert. She was fluent. She was well modulated today. She reports she continues to struggle with depression, but her main complaint is anxiety. She reports significant features of social anxiety. She feels awkward and anxious in new social situations, particularly if there are a number of people present. She reports periods of time where she is intensely anxious even without a social cue. She reports problems at times with difficulty falling asleep and sleep continuity problems, but less so on her current regimen. She reports of all the medicines that she has been on, Klonopin has been the most effective for the anxiety. She reports that in the past she has had the experience of auditory hallucinations that have a commenting or command quality to them. She denies having any psychotic symptoms now. She reports in the past, she has had extensive self-mutilation. Indeed on exam today, she has healing multiple lacerations over the left forearm in a complex spider web pattern. The patient denies any suicidal ideation or intent now. She did not have evidence of any flight of ideas or pressured of speech. She did not have evidence of any formal or informal thought disorder. She reports that she does have perimenstrual worsening of her mood. She reports marked irritability.

MENTAL STATUS EXAMINATION: On examination, the patient was alert. She was fluent. She was actually, initially, shy during the interview but actually opened up quite a bit and was quite forthcoming during the interview. She reports that she feels very sedated on the Depakote the way it is currently prescribed. She reports that the Lexapro has been helpful. She reports that she does have significant problems with her concentration and she is distractable. She can, however, enjoy reading. She reports that she is impulsive, sometimes saying or doing things on the spur of the moment that she later regrets. She reports that she has ups and downs in her mood. The patient did not have any flight of ideas or pressured speech during the interview. She denied any psychotic symptoms. There was no evidence of formal or informal thought disorder. She was not suicidal or homicidal.

MENTAL STATUS EXAMINATION: The patient was cooperative, pleasant, and maintained good eye contact. Speech was normal in rate and pattern. She was slightly hard of hearing. She reports her mood is a bit down, worried. Affect was sad. She denies current visual hallucinations but has had some in the last year. Denies other hallucinations and delusions, has a passive death wish, but not any active suicidal ideation. Scored 23/27, unable to see well to do the reading or the drawing.

MENTAL STATUS EXAMINATION: The patient has somewhat of a heavy growth of beard, dark brown hair, brown eyes. He makes good eye contact and is soft spoken. He describes his mood as sort of not too good. His affect is mood congruent, depressed, with some psychomotor retardation. The patient does not appear to be under the influence of any substances of abuse. Sensorium and cognition are grossly intact. Insight and judgment seem appropriate. The patient denies any thoughts of wanting to hurt himself or others at this time. He states he is not currently hearing voices or seeing visions. The last voices he heard were perhaps two days ago and only lasted for a few minutes. Insight and judgment at this time seem appropriate.

MENTAL STATUS EXAMINATION: The patient was lying in bed, sleeping, but easily awakened, maintained fair eye contact. Speech was slow with brief responses, but for the most part appropriate. She described her mood as okay. Affect was pleasant. She was able to brighten when talking about her work in the past. She denies hallucinations, suicidal ideation, death wishes, anger, or paranoia. She scored 15/30 on her Folstein, could only remember one of three items and do one part of the three-step command, could not copy or write a sentence, and could not subtract, and only got one letter right in spelling “world” backwards.

MENTAL STATUS EXAMINATION: Well-developed male of above-stated age. Grooming and hygiene were adequate. He cooperated to the evaluation. Speech was coherent. Thoughts were goal directed. Mood euthymic. Affect was reactive and he was readily laughing and joking. He was not in any distress. He was not observed to respond to unseen or internal stimuli. Denied suicidal or homicidal feelings. Denied hallucinations and delusions. He is alert and oriented. Memory is adequate. Concentration is good. Probably of average intelligence. Insight and judgment fair and intact. He is not impulsive.

MENTAL STATUS EXAMINATION: Alert and oriented x3. Cooperative with the interview. Makes fair eye contact. Speech coherent mostly. Psychomotor within normal range. Mood “depressed” with mildly anxious affect. At times, he becomes fidgety, somewhat distractible. No suicidal or homicidal thought, intent or plan. No auditory, visual or tactile hallucinations. No delusions of any kind. Sleep impaired. Concentration and memory not formally tested. Insight and judgment adequate.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old obese man who looked his stated age. He was fairly well groomed. He was subdued during the interview. However, he was cooperative with good eye contact. There was no psychomotor agitation or retardation observed. His speech was normal in volume but slow in rate. There was no formal thought disorder. His mood was dysphoric. His affect was blunted. He denied suicidal or homicidal ideation, intent or plan. He admitted to auditory hallucinations hearing evil forces chronically. He denied visual hallucinations. The patient was paranoid. He felt that people were always watching him. He also stated that he believed there were poisonous chemicals flying in the air and that he was born in heaven and that he was not from this planet. The patient was able to contract for his own safety. Insight into his mental illness was impaired and his judgment was also impaired. However, his impulse control was within normal limits.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old man who looks his stated age. He is of a tall, thin build. He was calm and cooperative during the interview. He maintained good eye contact. There was continual stereotyped rocking back and forth throughout the interview (the patient has had this rocking movements for several decades). The patient was fairly well groomed. His speech was normal in rate and volume, and there was no formal thought disorder. His mood was euthymic and his affect was blunted. He denied suicidal and homicidal ideation, intent or plan. He also denied auditory or visual hallucinations. There were no delusions elicited. The patient was able to contract for his own safety. His cognitive functioning was grossly intact as he was alert and oriented to place, person, and time. The patient’s insight, judgment, and impulse control are impaired.

MENTAL STATUS EXAMINATION: He is a fairly well-groomed (XX)-year-old male who appeared his stated age. There was no clinical evidence of psychomotor disturbance. He was cooperative, pleasant, and able to maintain adequate eye contact. His speech was coherent, spontaneous, appropriate with normal rate, volume, and rhythm. He described his mood as normal. Objectively, his mood was euthymic. His affect was full range and appropriate with spontaneous emotional reactivity. I could not elicit any clinical features of affective or psychotic illness. His memory was intact for recent and remote events. His behavior was appropriate. He was well oriented to place, time, and person. His concentration and attention were adequate. His general level of intelligence and fund of general knowledge were both within normal limits. His level of personal hygiene was good. He was able to communicate clearly and able to achieve goal directed ideas.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic female who presents alone for psychiatric evaluation. She is appropriately dressed for the season and well groomed. She is pleasant, cooperative, and relevant throughout the interview process. She establishes rapport easily and is alert and able to discuss past and recent events appropriately. She maintains normal eye contact and has normal motor controls. She describes her mood as quite irritable. Her affect is congruent. Her speech is mildly pressured and quite rapid. Her thoughts are well developed, well organized, goal directed, and appropriate. She denies sensory hallucination, illusion, or delusion. She denies suicidality, homicidality, self-injurious behaviors and contracts for safety. Her insight, memory and judgment are fair.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old man who looks younger than his stated age. He is of a short, thin build. He was calm and cooperative during the interview. He maintained good eye contact. There was no psychomotor agitation or retardation observed. His speech was normal in rate and volume. His mood was slightly dysphoric and his affect was blunted. He denied suicidal and homicidal ideation, intent, and plan. He also denied auditory and visual hallucinations. There were no delusions elicited. The patient was able to contract for his own safety. His cognitive functioning was grossly intact. Insight, judgment, and impulse control were within normal limits.

MENTAL STATUS EXAMINATION: The patient appears calm, relaxed. Injected sclerae and conjunctivae on his eyes but denies use of substances. No abnormal involuntary muscle movements noted. Sensorium and cognition otherwise grossly intact. Insight and judgment are fair and appropriate. The patient states he is not currently hearing voices, seeing visions or having any thoughts of wanting to hurt himself or others.

MENTAL STATUS EXAMINATION: In both individual and conjoined session, he is calm, relaxed, somewhat reserved and quiet but answers questions appropriately with straightforward, clearly understood English without accent. No abnormal involuntary muscle movements, tics or mannerisms are noted. The client describes his mood today as okay. His affect is somewhat repressed or distressed. The client denies currently or ever hearing voices, seeing visions or having any thoughts of wanting to be dead or hurt others. Sensorium and cognition are grossly intact. Insight and judgment are appropriate for age. There is no evidence of thought disorder.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic female who appears slightly older than her stated age. She is appropriately dressed for the season and well groomed. She does not have any involuntary motor movements nor does she appear to be responding to internal stimuli. She is alert and able to discuss past and recent events appropriately. She was pleasant, cooperative, and relevant throughout the interview. She makes normal eye contact and has normal motor controls. She describes her mood as upset and anxious. Affect is mildly blunted. Speech is mildly slowed but of normal rhythm, volume, and tone. She has no defects of articulation. Thoughts are well organized, well developed, appropriate, and goal directed. She denies suicidal or homicidal ideation or intent, and contracts for safety. She denies sensory hallucination, illusion, or delusion. Her memory is intact. Her insight and judgment are limited.

CHIEF COMPLAINT: Altered mental status.

ADMITTING DIAGNOSES:
1. Altered mental status.
2. Abnormal EKG, rule out acute coronary syndrome.

HISTORY OF PRESENT ILLNESS: This is a very unfortunate (XX)-year-old male whom the neighbors called the police on, as they had not seen the patient for several days. The neighbors yesterday had knocked on the door and there was no answer. They knocked on the door again today. When there was no answer, they called the police to check on him. The police entered the patient’s home and found the patient to be very confused. He appeared emaciated. The patient was brought to the emergency department for further evaluation.

PAST MEDICAL/SURGICAL HISTORY: Unable to obtain directly from the patient due to confusion. However, from old records, was admitted for a lower GI bleed and urinary retention in the past. There is a stated history of hypertension and BPH, status post TURP, also a history of a severe motor vehicle accident when he was a teenager.

FAMILY HISTORY: The patient was unable to provide. He was able to state that he is unmarried with no children. He has, he says, relatives in the area but was unable to remember any of their names or phone numbers. He did not have any information pertaining to his parents or whether or not he had any siblings.

SOCIAL HISTORY: The patient was a long-standing smoker, smoking half a pack per day for over 20 years. The patient denied any alcohol abuse or illicit drug use in the past; however, this cannot be reliable due to his state of confusion.

MEDICATIONS: Prior to admission are unknown. Due to the fact that the patient has never been at this facility before and with his confusion, he was unable to say what medications he was on.

ALLERGIES: UNKNOWN.

REVIEW OF SYSTEMS: Probably unreliable due to the patient’s confusion. However, when questioned, the patient denies any history of recent headache, blurred vision, sore throat, fever, chills, chest pain, palpitations, shortness of breath or congestion. Denied any abdominal pain. It was noted by staff that the patient was incontinent of urine when he came to the ER. The patient did state that he had some discomfort of his right foot with some swelling. He denied any fainting, blackouts or seizures. Denied any one-sided weakness or difficulty with speech.

PHYSICAL EXAMINATION: Please refer to the chart.

LABORATORY DATA: Please refer to the chart.

ADVANCED DIRECTIVES: Unknown. The patient will remain a FULL CODE. At this time, it is unknown as to whether he had a prior health care proxy. We will consult with social services to attempt to contact any living family members for further information.

ASSESSMENT AND MEDICAL DECISION MAKING:
1. Altered mental status, dementia versus delirium. CT was negative for bleed. There was some suspicion for evolving infarction. MRI was recommended due to the fact that there are no neuro deficits at this time other than some confusion. We will have a neuro consult in the a.m.
2. Abnormal EKG, rule out acute coronary syndrome. The EKG done upon patient’s arrival showed normal sinus rhythm, in the 80s, with a possible inferior and anterior infarct and T wave abnormalities in lateral leads suggestive of ischemia. That was done at 1900. Had the EKG repeated in the ER, which showed the same findings; although, in the lateral leads, T wave inversions were a little more pronounced. The patient does have history, seen in the old records, of left ventricular hypertrophy. I consulted with the cardiologist, who was in the ER at the time, who stated that EKG changes with the patient being totally asymptomatic could be related to severe LVH, so the plan is to admit the patient on telemetry. We will continue with serial enzymes. The patient could be started on a low-dose beta blocker, aspirin, subcutaneous Lovenox. Repeat EKGs daily x3 days. O2 at 2 liters via nasal cannula. We will do a fasting lipid profile in the morning and start a statin if appropriate. We will order an echocardiogram for the morning to evaluate left ventricular ejection fraction, which on echo that was done 7 years ago showed a normal ejection fraction, and have a cardiology consult in the morning.
3. Hypertension. According to the old records, the patient has a past history of hypertension. In the past, he was discharged home on atenolol, but the patient could not remember being on medications at this time, but in light of EKG changes, we will put him on low-dose beta blocker as stated above. The chest x-ray showed some mild congestion, and the patient does have edema in his feet and ankles so we will also add hydrochlorothiazide for blood pressure control and edema.
4. Gastrointestinal/deep venous thrombosis prophylaxis. The patient has a history of GI bleeding in the past. His hemoglobin and hematocrit are stable at this time. We will start the patient on Protonix p.o. daily, and as stated in #2, the patient will be on subcutaneous Lovenox for anticoagulation therapy.
5. Advanced directives. The patient is a FULL CODE with no health care proxy at this time. The patient states he has no children. We will have social services in consult to attempt to contact any family members, as the patient states he has many relatives in the area.

Further clinical decision making will be based on further diagnostic studies.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation for depressive episode.

IDENTIFICATION: The patient is a (XX)-year-old Asian male who was admitted to this facility via the emergency department.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old male was admitted to this facility via the emergency department. The patient presented with increased chest pain. The patient has a history of hypertension, insulin-dependent diabetes mellitus, hypercholesterolemia, congestive heart failure, history of angina, gastroesophageal reflux disease, apparent history of pancreatitis, and angioplasty.

Psychiatric consultation was requested to evaluate the patient who is currently presenting with episodes of feeling depressed. The patient states that, in the past, he was on therapies and currently has not been on any antidepressant. At times, he stated he feels somewhat demoralized.

The patient also said that he has multiple medical conditions. He has not been experiencing any episodes of hallucinations or delusional thought.

PAST PSYCHIATRIC HISTORY: Previous history of psychiatric hospitalization. He also has been seen in consult in the past for a previous history of depressive disorder.

PAST MEDICAL HISTORY: Significant for gallbladder disease, peptic ulcer disease, gastroesophageal reflux disease, angina, and arrhythmia. See history of present illness.

ALLERGIES: METFORMIN.

VITAL SIGNS: Blood pressure 162/82, respirations 18, pulse 82, and temperature 98.8.

REVIEW OF SYSTEMS: See history of present illness. He is still experiencing some episodes of chest pain. The remainder of the 14-point review of systems is negative.

MEDICATIONS: Novolin, Zestril, Zetia, Coreg, Plavix, NovoLog, glipizide, and Lipitor.

FAMILY AND SOCIAL HISTORY: The patient was born in (XX). Mother is 67 years of age and has a history of diabetes and coronary artery bypass graft. Father is in his early 70s and has had an operation on his disks and has some problem with his eyesight. The patient has history of attending special education classes. He is one of four brothers. He has been married close to 25 years and his wife is very supportive. The patient is on disability due to health problems and has a 12th grade education.

MENTAL STATUS EXAMINATION: This is a (XX)-year-old male who appears his stated age. He is lying in bed. Mood is depressed. Speech had normal rate. Thought process was goal directed. No auditory or visual hallucinations and no delusional thoughts noted. No suicidal or homicidal thoughts. The patient was alert and oriented x3. Good attention and concentration. Fairly good insight and judgment. Adequate impulse control during the interview.

DIAGNOSTIC IMPRESSION:
Axis I: Major depressive disorder, recurrent, without psychotic features.
Axis II: Deferred.
Axis III: See medical section.
Axis IV: Current health problems.
Axis V: Global Assessment of Functioning of 55.

SUMMARY AND RECOMMENDATIONS: The patient is a (XX)-year-old married male who was admitted to this facility through the emergency department. The patient is presenting with a depressive episode but no suicidal thoughts at this time. Given the patient’s current presentation, he could benefit from Lexapro 5 mg p.o. daily. We discussed with the patient the importance of compliance with psychotropic medication and therapy.

HISTORY OF THE PRESENT ILLNESS:  The patient and his brother have been in the foster home for the past two months. He is very lovable and affectionate. He is aggressive and can be violent. He can be labile and will attack his brother unprovoked. He is easily frustrated and has temper tantrums. He will throw himself on the floor when frustrated. He sleeps well but moves around a lot while sleeping. Occasionally, he will fall to the edge of the bed. His bed is low to the floor. He eats well, is toilet trained, and is dry at night. Fluids are restricted after dinner. He is unable to dress himself and seems to have difficultly learning his activities of daily living. He needs constant monitoring and redirection. He will push others and throw things. He is difficult to manage when others visit. He returns from visits with his mother agitated, aggressive, and unruly. It takes up to 24 hours for the patient to calm down after visits with his mother. There is no strange or unusual behavior reported.

PAST PSYCHIATRIC TREATMENT HISTORY:  The patient sees (XX) for weekly therapy.

PAST MEDICAL HISTORY:  The patient has a history of asthma as well as anemia. He was taking iron supplements, which were recently discontinued, and his asthma inhaler, as needed, was also recently discontinued as he has not had symptoms in a long time.

MENTAL STATUS EXAMINATION:  The patient was well groomed and appropriately dressed. He was marginally cooperative and engaged with encouragement. He was well related and displayed normal psychomotor activity. Attention span was adequate. Mood was euthymic. Affect was labile. He is easily frustrated, but he is also able to be redirected. Speech displayed normal rate, rhythm, and tone. No significant articulation difficulties noted. His thoughts are goal directed. There is no evidence of auditory or visual hallucinations nor delusional perceptions. There is no evidence of suicidal or homicidal ideation, intent or plans. He is alert and oriented x3. Memory is adequate. Concentration was adequate while playing. He needed constant supervision and redirection throughout the interview. Insight is poor. Judgment and impulse control are both poor.

SUMMARY:  The patient is a (XX)-year-old boy who was placed in foster care program on MM/DD/YYYY. He has a history of aggression, defiance, and oppositional behavior. He seems to require constant monitoring and very close supervision due to his unprovoked aggressive outbursts.

DIAGNOSTIC IMPRESSION:
AXIS I:
1. Oppositional Defiant Disorder.
2. Adjustment Disorder with Disturbance of Conduct due to increased aggressive and violent behavior following maternal visits.
AXIS II: Expressive speech delays.
AXIS III: Asthma and anemia, history of both, in remission.
AXIS IV: Moderate, ongoing foster care, significant dysfunction in his nuclear family.
AXIS V: Current Global Assessment of Functioning is 45.

RECOMMENDATIONS:
1.  This child should continue weekly psychotherapy.
2.  Extensive structure and support is required for this young man. He needs constant redirection and encouragement for appropriate behavior.
3.  This child will require special education services in order to develop appropriately and be able to function academically. He should be evaluated as soon as possible for special education placement and services as well as possible speech therapy, physical therapy, and occupational therapy.
4.  This child requires speech therapy evaluation.
5.  A positive behavior modification plan would be very helpful in order to encourage appropriate behavior.
6.  Community-based services are recommended for his health and well being.
7.  Medical followup and monitoring for his history of asthma and anemia, in remission.

This is a 60-minute established psychodynamic psychotherapy visit.

DIAGNOSES:
AXIS I:  Major depressive disorder, recurrent, severe; anxiety disorder, not otherwise specified.
AXIS II:  Deferred.
AXIS III:  History of hypertension.
AXIS IV:  Divorced, living alone, single, family conflict and job difficulties.
AXIS V:  Global Assessment of Functioning 70.

INTERIM HISTORY:  The patient returns today for established weekly visit. He is scheduled to meet with this examiner as well as supervising psychiatrist, who arrives after the visit is underway for 15 minutes and stays for the remainder of the visit. The patient is on time, having come in the rains, is pleasant and easily engageable.

We are now in the treatment phase of psychodynamic psychotherapy and things discussed today surround the patient’s anxiety, impending conflict, and his difficulty trusting his instincts, particularly after the fact, which stems back to his family conflict as a child but which he has also carried forward, and it impacts his adult relationships and job performance.

The patient shares more this week than he has previously, possibly due to the presence of supervising psychiatrist. He again reveals it is difficult for him to follow his own train of thought; however, finds it helpful to talk through his anxiety and try to understand where it comes from and how he can regain control.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old Hispanic male, appearing stated age, with black hair, well groomed, casually attired, coming from work and wet from the rain with good eye contact, spontaneous fluent speech, euthymic mood with congruent affect, upbeat and bright. Thought process linear and goal directed. Thought content negative for any suicidal or homicidal ideation. No harmful intent or plan. No auditory or visual hallucinations, no signs of responding to internal stimuli or formal thought disorder. Estimated intelligence is above average with good insight and fair judgment.

ASSESSMENT:  The patient is a (XX)-year-old divorced Hispanic male with past psychiatric history of depressive disorder, recurrent, severe and anxiety disorder, not otherwise specified, who presents for established weekly psychodynamic psychotherapy visit with supervisor psychiatrist present, continuing in the treatment phase of therapy and identifying patterns of anxiety and negative thoughts that influences feeling and behavior.

PLAN:  We will continue to meet weekly at 5 p.m. on Wednesdays. Our next appointment is scheduled for MM/DD/YYYY at 5 p.m. The patient agrees to contact this examiner with nonurgent issues only by voice mail and to seek emergency mental health services should his personal safety become an issue and to call 911.

He will continue to be followed by Dr. John Doe in the psychopharmacology clinic for his medication prescriptions as well as with primary care provider at the adult primary care clinic.

REFERRING PHYSICIAN: John Doe, MD.

REASON FOR CONSULTATION: Agitation.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old single Hispanic male living well with his son, who was admitted for hematuria. Psychiatric consultation was requested to evaluate his agitation. Most of the history was obtained from the patient who is considered to be a partial informant. The patient claims that he has been residing with his grown children. Lately, he has been living with his son. The patient could not tell me the reason for his hospitalization, and in fact, he has been quite forgetful and does not realize that he has been hospitalized. The patient was rather social during the evaluation; although, he was extremely agitated, for which p.r.n. medications were necessary last night. On inquiry, he denies any previous history of sadness of mood, loss of interest in pleasurable activities. No recurrent suicidal ideation. He denies any auditory or visual hallucination or delusional thinking. The patient generally minimized his symptoms and also denies any memory problems; although, he clearly has been forgetful.

PAST PSYCHIATRIC HISTORY: He denies any previous psychiatric hospitalization or treatment. Old records indicate that the patient has had memory problems, possibly consistent with dementia.

PAST MEDICAL HISTORY: The patient has a history of prostate cancer. He also has colon cancer and underwent a colonoscopy, which was complicated with a perforation, for which he underwent surgery, as per the old records. The patient now presents with hematuria, anemia, and possible GI bleeding again. No history of seizures. The patient denies cardiac problems.

MEDICATIONS: The patient is on Ativan 1 mg three times a day, Haldol p.r.n., and Levaquin 500 mg.

ALLERGIES: None known.

SOCIAL HISTORY: The patient was born and raised in (XX). The patient has a 12th grade education. The patient claims that he has been married, and his wife is around; although, he is not considered to be a reliable informant. The patient has been residing with his children. The patient denies use of alcohol or drugs and denies any active medical problems. No significant family psychiatric history elicited at this time.

REVIEW OF SYSTEMS: Please refer to the H&P.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic male who is calm and cooperative with the interviewer. Good eye contact. Speech is spontaneous with occasional looseness of associations. He is slightly hard of hearing. The patient denies any auditory or visual hallucinations or suicidal or homicidal ideation at this time. No definite delusions are noted at this time. He is alert, however, disoriented in time and place. Poor short-term memory and poor recall; however, longer-term memory is relatively intact. Episodic psychomotor agitation noted since admission. His insight and judgment is poor. His impulse control remains unpredictable.

DIAGNOSTIC IMPRESSION:
Axis I:  Senile dementia with behavioral problems.
Axis II:  None.
Axis III:
1.  Prostate cancer.
2.  Colon cancer by history, status post colon perforation and surgery.
3.  Anemia.
Axis IV:  Advanced age, multiple medical issues.
Axis V:  Global Assessment of Functioning 40 upon evaluation; past year, unknown.

PLAN:
1.  We will suggest starting him on Aricept 5 mg p.o. daily and Risperdal 0.5 mg at bedtime and agree with use of Ativan to control his agitation. Dosage will be gradually reduced.
2.  We will try and reach his family and obtain a more reliable history to assess his support system and placement issues.
3.  We will follow the patient and monitor his progress closely. We agree with CAT scan of the brain to rule out any intracranial pathology at this time.

PSYCHIATRIC INTERVIEW:  The patient was cooperative in the interview. He spoke with some degree of slurred speech. He stated that he had been here two years and before that had gone to the outside facility because of angry behavior, including destructive behavior at home with his father. He stated that his father lives with his stepmother and three sisters. The patient stated, at this point, that he is looking forward to residential placement. He stated proudly that he has been participating in sports, particularly basketball, and hopes to have a career in that sport. He stated his hobbies were cooking and reading and stated that he feels he has matured while here and has better control over his temper. He said that his relationship with his father has improved and has had some home visits but does not want to live at home. He denied any appetite or major sleep disturbance at this time. He denied any substance abuse and denied any depression. He denied hallucinations or any suicidal or homicidal ideation. He stated that he has been compliant with his medication regimen of Abilify 5 mg in the morning, Clozaril 200 mg three times a day, Tenex 1 mg in the morning and 2 mg in the afternoon, and lithium carbonate 600 mg in the morning and 900 mg at night. A level from January of lithium was 0.9 mEq/L. There was no evidence of any psychotic process to his thinking, and no delusional thought content was evident.

DIAGNOSES:

AXIS I:

1.  Bipolar, not otherwise specified.
2.  Nocturnal enuresis.
3.  Pervasive developmental disorder, not otherwise specified by history
4.  ADHD by history.

AXIS II:  Mild intellectual disability.

AXIS III:  No major medical issues.

AXIS IV:  Past stressors – severe, early disruptions in development. Current stressors – moderate, upcoming possible referral to residential placement.

AXIS V:  GAF is currently 60.

RECOMMENDATIONS:  At this point, the patient is cooperative in being referred to adult residential placement. The patient will benefit from ongoing supportive psychotherapy and vocational counseling, and at this time, should remain on his current regimen, which includes monitoring of his CBC while on Clozaril.

Sample #2

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Psychiatric evaluation for followup.

IDENTIFYING DATA:  The patient is a (XX)-year-old female who was admitted to this facility via transfer from an outside facility. The patient initially was in the psychiatric medicine unit and was later transferred to the medical floor due to failure to thrive. The patient has a medical history that is significant for angina, osteoporosis, chronic pain, COPD, and anorexia. The patient has been having periods of increased anxiety and also had poor p.o. intake, low energy level, and difficulty sleeping. Vision was also impaired with an element of suspicious and paranoid-type behavior. The patient is on lorazepam 0.5 mg b.i.d. She is also on Remeron 15 mg at night. The patient is reported having, at times, some episodes of depression. The patient was on Valium in the past, and this was discontinued and started on Ativan.

PAST PSYCHIATRIC HISTORY:  Previous history of psychiatric hospitalization. The patient had some anxieties and major depression and cognitive decline.

PAST MEDICAL HISTORY:  See history of present illness.

ALLERGIES:  PENICILLIN AND SULFA.

MEDICATIONS:  Macrodantin, Roxicodone, MiraLax, lorazepam, aspirin, Protonix, and Lovenox.

PHYSICAL EXAMINATION:  VITAL SIGNS: Blood pressure 130/76, respirations 18, pulse 88, and temperature 98.4 degrees.

PERSONAL AND SOCIAL HISTORY:  The patient was born in (XX) and lives in (XX) with two sons. She grew up in (XX). No known family psychiatric history. There is some history of addiction.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old who appears stated age, lying in bed. The patient was cooperative during the interview. Speech was normal in rate. Thought process was goal directed. No auditory or visual hallucination. Some guardedness but no systematized delusional thought noted. No suicidal or homicidal thought. The patient was alert and oriented x3 with some difficulty with recall and with attention and concentration. There was some limited awareness of current events, able to identify two or more objects, fair vocabulary.

DIAGNOSTIC IMPRESSION:
Axis I:
1.  Delirium disorder, superimposed.
2.  Dementia disorder.
3.  Anxiety disorder, not otherwise specified.
Axis II:  Deferred.
Axis III:  See medical section.
Axis IV:  Current health problem.
Axis V:  Global Assessment of Functioning of 50.

RECOMMENDATIONS:  The patient is a (XX)-year-old who was admitted to this facility. The patient presented with increased episodes of anxiety. At this time, given the patient’s current presentation and partial response to Ativan, therefore, recommended increasing Ativan to 2.5 mg p.o. b.i.d.

HISTORY OF PRESENT ILLNESS:  The patient is here today to follow up on attention deficit hyperactivity disorder. One month ago, she saw her primary care physician and was prescribed 20 mg per day amphetamine/dextroamphetamine ER. Since that time, she says she has been tolerating the medication well without chest pain, palpitations, anorexia, weight loss, or insomnia. She does complain of a dry mouth, which she relieves by drinking water throughout the day. The patient says that since beginning the medication, she noticed that she has been more alert, particularly with driving. However, she is wondering if a somewhat higher dose might give her additional benefit and help her more with her school work, as she still is having a difficult time concentrating on that. The patient continues to take Prozac 40 mg daily the week of her period only.

REVIEW OF SYSTEMS:  No weight loss. No depression or anxiety. No chest pain or palpitations. Positive for dry mouth.

PHYSICAL EXAMINATION:  In general, the patient is in no acute distress. Blood pressure is 92/62, pulse 68, respiratory rate 20. In general, this is a well-developed, well-nourished appearing woman, in no acute distress. Mental status exam is intact without overt depression or anxiety.

ASSESSMENT:  Attention deficit hyperactivity disorder, improved on amphetamine and dextroamphetamine ER 20 mg.

PLAN:  We will give the patient a trial of amphetamine/dextroamphetamine ER 25 mg, and she will see if this increases the benefit she is getting from the medication. She is scheduled for a physical and she will follow up on this at that time. Encouraged her to call us if she develops any new signs and symptoms or if intolerable side effects or dry mouth on the 25 mg dosage occurs.

Psychiatry Discharge Summary

This assessment started at 11:30 a.m. and ended at 11:45 a.m.

HISTORY:  The patient is an (XX)-year-old boy who will be in the (XX)th grade at (XX) Elementary. He carries a diagnosis of ADHD, combined type, with ODD. Currently, he is on Metadate CD 20 mg q.a.m. The patient reported on time for this assessment. He was accompanied by his mother and resource coordinator. The patient is doing well since he was switched to Metadate CD. No acute management problems reported. No symptoms suggestive of psychosis or mania reported. He is compliant with his medications.

MENTAL STATUS EXAMINATION:  No clinically significant features were noted. He describes his mood as fine. His affect is bright and full range. He does not appear to be responding to any abnormal perceptions or delusions. His judgment is age appropriate.

DIAGNOSES:
1.  Attention deficit hyperactivity disorder, combined type.
2.  Oppositional defiant disorder.

RECOMMENDATIONS:
1.  The patient does not pose any imminent danger of harming himself or others; therefore, his outpatient status should be maintained.
2.  Metadate CD 20 mg p.o. q.a.m. should continue as he is not reported to have any major side effects associated with it.
3.  The patient should continue to follow up with his RN at regular intervals.
4.  The patient should return for reassessment.