Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Chief Complaint: Follow up History of Presenting Illness: Mr. Gerald is 58-year-old AA male admitted to SBGC on 10/8/21 due to history of HTN, chronic ETOH use, tobacco use, Wernicke's encephalopathy and unspecified psychiatric history. He was seen for follow up via telemedicine. He was selectively mute and could not talk to us much. Nodded head to most questions. Patient is a poor historian and has a history of given conflicting information. Staff report that appetite and sleep varies. He is being managed with Aricept 5mg for dementia and Cogentin 0.5mg for EPS. Ativan 1mg PRN for agitation. Nursing to continue to document behavior to direct further treatment plan. Verbalized understanding. No change in status. Denies suicidal or homicidal ideation. Denies any issue or discomfort currently. Patient denies current SI/HI/AVH/Paranoia/Delusion. Current Medication: As per Matrix medication lists for medical. Psychiatric medication: None Past Psychiatric History: Unknown Past Psychiatric Hospitalization: Unknown History of Suicide Attempts or Thoughts- Unknown Previous Psychiatric Medications: None PTSD: Y/N- Unknown. Family Psychiatric History: Unknown Medical History/Review of Systems: See Matrix for medical diagnosis. Allergies Drug: NKDA. Food Allergies: NKFA Surgery: Y/N- Unknown. Sleep and Appetite Varies. Normal Developmental History: None Exposure to Drugs/medication/Alcohol: Y/N-Unknown Speech/Language delays: Y/N- Yes Sexual Abuse or Physical abuse: Y/N-Unknown Social History: Unknown Sexually active. Are you in relationship: Unknown? Family Structure: Unknown Favorite/Leisure activity: Y/N: Unknown Educational History/Career: Unknown Work history: Unknown Substance Use History: Unknown. Legal History: Y/N- Unknown Mental Status Examination: General Appearance: Neat & clean, casually dressed in good hygiene. Eye contact: Normal Psychomotor Activity: Normal Memory: Long term and short-term memory not intact. Attention: Reduced SPEECH: Decreased speech in amount, rate, and volume. MOOD: objectively Poor. AFFECT: Flat and anxious. THOUGHT PROCESS: Not appropriate. THOUGHT CONTENT: Denies SI/HI. PERCEPTIONS: Denies AVH sensorium. INSIGHT: Poor JUDGMENT: Poor COGNITION: Poor Language. normal. Diagnosis: F03.20 Dementia. Suicidal ideation/HI - Denies Suicidal or homicidal ideation. PROTECTIVE FACTORS: Family support RISK ASSESSMENT: Low SAFETY PLAN RECOMMENDATIONS: Notify staff if feeling Suicidal and call 911 for suicidal attempt. Psychosis: - Denies Paranoia and delusional. Prescription: No medication at this time. Medication Education: Aricept 5mg at bed time for dementia. Cogentin 0.5mg for EPS. Ativan 1mg every 6hrs PRN. Non-Pharmacological Education Recommended: Continue to use positive coping skills as needed. Identify triggers and address them proactively. Plan: In 90 days, there will be improvement in memory and concentration. Fall precaution in place Follow up in 2 to 4 weeks.