Write Follow Psych Explained for Students (Easy Guide)

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Key Explanation

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Original Question

Write an follow up PSYCH VISIT, chief complaint, , Psychiatric visit HPI, current Psych meds, exam, diagnosis and recommended Plan and rationale for med changes for an 76years old female who resides at a skilled facility currently seen today for a follow up visit with hx of MDD , epilepsy unspecified, and delirium condition due to known physical condition. Her delirium has now resolved. She is currently on Paroxetine 20mg for MDD Quetiapine fumerate 25mg daily Gabapentin 800mg daily for chronic pain. Provider received a concern from pharmerica pharmacy stating the resident is receiving the antipsychotic quetiapine25mg PO qhs requesting a trial reduction with the goal of discontinuation. This provider spoke with the patient and patient has been on Seroquel 25mg at HS daily since 1998 since she had her brain surgery and spinal surgery with no shunt been put. She said without the Seroquel she gets intense headaches and faints and spinal fluids builds up. She said she also takes Gabapentin 800mg after the spinal sugery. She said she sleeps like a log. She said her headaches gets horrible when not quetiapine. She said right now her main worry is that she caught a cough since she was admitted at the facility and it will not go away. The plan is to continue current orders including orders for quetiapine.

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