DATE OF CONSULTATION: MM/DD/YYYY
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.
