IDENTIFYING AND BACKGROUND DATA: The patient is a (XX)-year-old Caucasian male who was referred to this facility from (XX) where he was admitted for increasing aggression towards his family. At this time, the patient is being considered for adult residential services. The patient has lived with his adoptive family since the age of (XX) and has attended multiple foster homes before going to live with his adopted family and was diagnosed with pervasive developmental disorder and attention deficit hyperactivity disorder as a child. The patient’s milestones were delayed, and he reportedly did not speak until the age of (XX). Nocturnal enuresis has been a chronic problem. He has also had difficulties with expressive and receptive language function and difficulties with articulation. There is a history of difficulty in social situations. He was hospitalized at a facility for eight months before coming here. He was diagnosed at the outside facility with bipolar disorder, NOS. Psychological evaluation there determined a diagnosis of mental retardation and a Full Scale IQ of 70 was determined. For further information, please refer to the record and psychiatric assessment from the outside facility.
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.
