DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of agitation and paranoid behavior.
IDENTIFICATION: The patient is a (XX)-year-old African-American female who was admitted to this facility via the emergency department.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who was admitted to this facility via the emergency department. The patient is a resident of a skilled nursing home facility. The patient was presenting with an episode of questionable chest pain. She has a history of frequent urinary tract infections, history of asthma, and previous history, several years ago, of hepatitis. The patient has had a history of progressive cognitive decline. The patient has been a resident of the nursing home for a few years now. The patient is reported to have periods of increased suspiciousness and paranoid behavior. It was reported that the patient often was very reluctant in taking medication and sometimes the level of paranoia interferes with her care, where she is refusing care, does not want to eat, feels that food has been poisoned, and can be very oppositional with staff.
The patient has not received any recent psychiatric treatment for this behavior, but she has a previous history of depressive disorder. She did receive antidepressant medication, Prozac. Also, she has a previous history of excessive symptoms of anxiety, for which she received Xanax and Ativan. The patient has a history that dates back to several decades ago when she sustained a head injury, and there were changes in her behavior. The patient was unable to return back to work after this incident. At that point, the patient was having some behavioral changes. Most recently, the patient has had a decline in cognition, problems with short-term memory, attention, concentration, and reasoning.
There is no history of alcohol abuse or abuse of prescription medication. She does not smoke cigarettes. She has been living in the nursing home in recent years. The patient always had multiple complaints about her care, even when the care was appropriate. At this time, she is asking to return home, but the family described the patient is unable to care for herself and that it is not feasible since the level of the support is not there for her to return after having multiple complaints of the current facility where she resides.
PAST PSYCHIATRIC HISTORY: Previous history of psychiatric treatment. No history of inpatient treatment. No history of suicidal attempt.
FAMILY PSYCHIATRIC HISTORY: Negative.
MEDICAL HISTORY: See history of present illness.
PHYSICAL EXAMINATION: Blood pressure 112/68, respirations 18, pulse 80, and temperature 97.4.
REVIEW OF SYSTEMS: The patient is unable to provide reliable information regarding 14-point review of systems.
SUBSTANCE ABUSE HISTORY: No history of alcohol abuse or abuse of prescription medication.
MENTAL STATUS EXAMINATION: This is a (XX)-year-old female who was lying in bed. The patient has difficulty hearing. Very suspicious with periods of agitation. Thought process was illogic, thoughts tangential. Is paranoid and clearly responding to internal stimuli. No suicidal or homicidal thoughts. She is alert and oriented only to person. Impaired attention and concentration. Impaired insight and judgment. Poor recall. No awareness of current events. Unable to name objects or repeat phrases.
DIAGNOSTIC IMPRESSION:
Axis I:
1. Superimposed delirium disorder.
2. Dementia disorder with behavioral disorder.
3. Psychotic disorder, not otherwise specified.
4. Cognitive disorder secondary to head injury.
5. History of depressive disorder.
Axis II: Deferred.
Axis III: See medical section.
Axis IV: Current health problems.
Axis V: Global Assessment of Functioning of 40 to 45.
SUMMARY AND RECOMMENDATIONS: The patient is a (XX)-year-old female who was admitted to this facility. Psychiatric consultation was requested to evaluate the patient who has presented with periods of agitation and restless-type behavior. At this time, we discussed with family initiation of a trial of Haldol 0.5 mg IV q.12 h. x 48 hours and also consideration in the future of a small dose of Risperdal 0.25 mg at bedtime. Continue to provide the patient with frequent orientation.
Thank you for allowing me to participate in the care of this patient.
