How to Answer Write Initial Psychiatric Questions (Complete Guide)

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Original Question

Write an Initial Psychiatric Evaluation/ diagnosis, Psychiatric visit HPI, social, screening tools, MSE, Family History, diagnosis and recommended Plan for a 60years old male with who currently resides at Sharon care facility post AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY and is receiving cepalaxin 500mg BID. PRESENCE OF RIGHT ARTIFICIAL KNEE JOINT. He has psychiatric history of Insomnia, delirium, Anxiety Disorder and Claustrophobia. He is married, have two children and they visit very often. He was recently (2/12/25) started on Trazodone 50mg PRN for HS for insomnia. He is taking Fluxoetine 20mg daily for depression. Patient said I am depressed all the time since I started dealing with my right lower leg amputation. . I ma not able to do the things I used to do. I am tired all the time. I do not like the CPAP since I am claustrophobic and the staff here keep insisting it will make me feel better. He said he is married and wife is very supportive of his care. I started the Trazodone yesterday and I was able to sleep abit better. I have two children and they visit all the time.

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