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Original Question
Write an follow up PSYCH VISIT, Psychiatric Evaluation/ diagnosis, Psychiatric visit HPI,, screening tools, MSE, diagnosis and recommended Plan for a 75years old male who resides at Sharon care facility-A skilled nursing facility. Patient was recommened to be seen per social services for suicidal ideations. Current Psychiatric Disorder are Insomnia, MDD and Generalized anxiety. Physical diagnosis of OTHER CEREBRAL INFARCTION DUE TO OCCLUSION OR STENOSIS OF SMALL ARTERY During the assessment, patient said I am not doing well. I have body aches. My mood is getting down. Yesterday I was abit excited but today I am feeling horrible. My sleep and appetite is good. When asked if he is thinking about suicide, he said yes because I watch it on TV very often. I lay in bed here and I watch so many suicidal programs. When asked about if he has any means for the suicide. He said no means available at the facility. He said he however owns a gun at home. Patient said he is no longer hallucinating ND NO DELUSIONS, I really suffered then when I was in the hospital. Current Medications Bupropion XL 150mg (Give 3tabs ) in the morning for MDD Amitryiptyline 10mg HCL for anxiety. Seroquel 25mg daily for hospital acquired delusions and Hallucinations Escitalopram 20mg for MDD. Consider to d/c SEROQUEL Since no more hallucinations and delusions
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