Read attached pleased original due 02/03/2020 at 11pm Week 9

33 yo BM BA by police;

on evaluation, pt agitated, combative, threatening, requiring ETO for protection of self and others

Pt was not responding to multiple attempts at redirection

Will admit to IP involuntarily for further evaluation and treatment iun a secure, monitored environment

Past Medical/ Family/ Social History

Psychiatric history: Hospitalization.

Substance Use History: Alcohol: Denies alcohol use, Tobacco: Denies tobacco use, Drugs: Denies drug use.

Medical history: Reviewed as documented in chart.

Surgical history: Reviewed as documented in chart.

Family Medical history: Reviewed as documented in chart.

Family Psychiatric history: Negative.

Social history: Occupation: Unemployed.

Review of Systems

Constitutional symptoms: No fever, no chills.

Skin symptoms: No rash,

Eye symptoms: no Recent vision problems

ENT: no Ear pain, no Sore throat.

Cardiovascular symptoms: No chest pain, no palpitations.

Respiratory symptoms: No shortness of breath, no cough.

Gastrointestinal symptoms: no nausea no vomiting.

Genitourinary symptoms: no Hematuria

Musculoskeletal symptoms: no Joint pain

Physical Examination

General appearance: No acute distress.

Eye: Extraocular movement: Within normal limits

Ears, nose, mouth and throat: Oral mucosa moist

Neck: Trachea midline.

Heart: Regular rate and rhythm.

Respiratory: Respirations nonlabored

Abdominal: Nontender

Extremity: Normal range of motion

Neurological: Alert

Medical Decision Making

Differential diagnosis

Acute psychosis

Mental Status Examination

Mental Status Examination Orientation Awake, person, , place, Appearance Disheveled, Behavior Agitated, Speech Unable to assess, Concentration/Memory Unable to assess, Mood Anxious, Affect Labile, Thought Process Unable to assess, Thought Content Unable to assess, Insight Poor, Judgement Poor.

Impression and Plan

Diagnosis

Acute psychosis (ICD10-CM F23, Discharge, Medical)

Discharge plan

Condition: Guarded.

Admit: To Inpatient Unit.

Counseled: Patient.

Suicide ideation: No.

Homicide ideation: No.

Psychiatrically stable: No.