Patientis64yearsoldcasestudy..docx
Patient is 64 y/o African American male with PMHX of Dementia, Schizophrenia, Weakness and General debility. He was seen for follow up. Patient still slightly symptomatic and will continue with adjusted Trazadone 100mg once a day at bed time. Nursing will continue to monitor for behavioral issues and document for follow up. During this visit, he was seen in Solarium with other peers. Acknowledge greetings from Provider by nodding his head. Verbalized no complain. He is cooperative, although he has reduced interaction with poor concentration and delay in his responses. Still not able to give any sensible information due to very substantial progressive cognitive impairment. Patients remain on Depakote 250 mg thrice daily. Will commence gradual drug reduction when stable. He is still quite symptomatic. Total ADLs care provided with one Person assist. No behavioral issue noted during this visit. He is stable clinically at his usual baseline. Fall and safety precaution maintained. He is being managed with Trazodone 100mg at bed time to aid with sleep and depression. Patient is benefitting from Depakote 250 mg thrice daily for mood stabilization and Ability 5mg daily for aggressive behavior/thoughts disorder and will continue with it. He has a good appetite and varied sleep. Alert and oriented x 1. He has poor insight, judgement, and concentration. Patient is compliant with treatment. Patient denies current SI/HI/AVH. Denies depressed or anxiety feelings.
Current Medication: As per Matrix medication lists for medical.
Psychiatric medication: Currently on Exelon 9.5 mg/24hr transdermal daily, Namenda XR 28 mg daily dementia, Trazodone 100mg daily for depression/ sleep. Depakote 250mg thrice daily and Abilify 5mg for aggression. Will continue with his current treatment regimen as the patient is still symptomatic. No GDR currently.
Past Psychiatric History: Yes
Past Psychiatric Hospitalization: Unknown
History of Suicide Attempts or Thoughts- Unknown
Previous Psychiatric Medications: None
PTSD: Y/N- Unknown.
Medical History/Review of Systems: See Matrix for medical diagnosis.
Allergies Drug: NKDA.
Food Allergies: NKFA
Surgery: Y/N- Unknown.
Sleep Pattern: Varied sleep.
Appetite: Normal
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, Has poor concentration.
Orientation: Person and Place (A/O X 1)
Attention: Reduced
SPEECH: Decreased speech in amount, rate, and volume .
MOOD: objectively Sad, guarded, suspicious, restricted and inappropriate.
AFFECT: Flat and anxious and not goal directed.
THOUGHT PROCESS: Not appropriate.
THOUGHT CONTENT: Denies SI/HI.
PERCEPTIONS: Denies AVH sensorium.
INSIGHT: Poor
JUDGMENT: Poor.
COGNITION: poor
Language :Normal.
Suicidal ideation/HI - Denies Suicidal or homicidal ideation.
SAFETY PLAN RECOMMENDATIONS: Notify staff if feeling Suicidal and call 911 for suicidal attempt.
Psychosis: - Denies Paranoia and delusional currently.
Diagnosis:
F31.9 Bipolar disorder.
F 20.9 Unspecified Schizophrenia.
F03.90 Dementia
F33.2 MDD
R41.3 Amnesia
Medication Prescribed:. Exelon 9.5 mg/24hr transdermal daily, Namenda XR 28 mg daily dementia, Trazodone 100mg tabs daily for depression/ sleep. Depakote 250mg thrice daily and Abilify 5mg for aggression. Continue with current medication No GDR currently as he is symptomatic. Standing order for Depakote level twice yearly in place.
Medication Education: Educated patient and staff on medication side effect. Monitor vital signs before giving Trazodone medication to rule out hypotension and to watch out for priapism. Verbalized understanding.
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 cognition, moods and decrease in aggression.
Follow Up: 2 to 4 weeks.
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