How to Answer Write History Present Questions (Complete Guide)
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Original Question
Write History of present illness and recommended plan for a 71years old Caucasian female with history of severe depression catatoniawith Psychosis, schozophrenia and .Medical History of left MCA stroke, DVT and heart failure. Assessment done with her Sister in the room and she was very contributive to patient’s history. The patient spoke very little but was cooperative. SOCIAL FACTORS: Currently residing in a skilled facility for rehab in a short stay. Has always lived with her sister who takes care of her and she is the POA. Never married. Denies alcohol use and recreation drugs. Sister verbalized Patient is not able to ask for her Lorazepam to manage catatonia. Per assessment, there is improvement in catatonia. Patient’s sister verbalized that her mood is on and Off. Some days she is very copperative, interactive and all happy and the next day she is down, sad, depressed and does not even want to talk. PATIENT ALSO VERBALISED being in the nursing home is a very sad thing and she likes it home where she can drive around with her sister and do some fun things. Sleeps ok 9hours. Appetite depends on the food served (good some days and bad some days). Current Meds: Memantine for cognitive impairment Sertraline 50mg for depression (Give 3tabs in the morning) Lorazepam 2mg every 12 hours PRN for catatonia Mirtapzipine 15mg at HS
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