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Write an Initial PSYCH VISIT, chief complaint, , Psychiatric visit HPI, current Psych meds, exam, social history,, screening tools and results MSE, diagnosis and recommended Plan (medication and dosages), rationale for using the medications for 75years old male referred to be seen for initial psychiatric visit for diagnosis of Related to multiple psych medications discontinued in the hospital. He is here post hospitalization of surgical aftercare. The assessment was done in the patient’s room in the presence of his daughter and he consented to her staying. The patient said he was taking many mood stabilizers for his Bipolar (Depakote, lithium and others he could not remember the name) but when he was admitted at the hospital 2weeeks ago, they got d/c. Current Medications include : Depakote 500mg oral DR (GIVE 1TABLET bid) for Bipolar disorder. Melatonin 1mg (Give 4tabs PRN at HS) He said he feels he is getter better but he gets tired easily after working with physical therapy. He said he usually gets to sleep very early by 5pm and he wakes up by 2am and then able to fall back asleep by 2:30am. He said he does not take his melatonin cx he does not have any problem falling asleep. He said he has been on Depakote for 22years. His mood was calm and stable with the Depakote 50Mg BID now. HE Said he worked as a electrical engineer and he had a good career and earned good money.

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