Write History Present Explained for Students (Easy Guide)

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Original Question

Write History of Present illness, MSE and recommended plan for an 81years old Caucasian female who is residing at a skilled facility (Cottesmore OF LIFE CARE) for strengthening. Patient is seen for initial psych evaluation and medication management. She has passed pschy history of depression, cognitive communication deficit. Patient said she is very happy today because she had a good shower after a very long time but however tired because they had to use mechaninical lift to get her to the bathroom and back. Assessment was done with her husband in the room. She is happily married with a total of 6kids who are all doing well. She currently lives with her husband at home and their cat and she cannot wait to be discharged from here. Patient said she sleeps in 2hours increments but easily falls back asleep. She verbalized poor appetite because of the food since all her years married, her husband cooked for her everyday and he is the best cook ever she said. She said she is trying to sleep less during the day. She was and lovely and cooperative with the assessment. She verbalized being anxious as she is not in her usual surrounding. Denies use of alcohol, illicit drugs and smoke. Current Meds: Duloxetine 150mg at HS for depression Seroquel 25mg at HS Gabapentin 300mg.

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