DATE OF CONSULTATION: MM/DD/YYYY
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.
