DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
IDENTIFYING DATA: This is a (XX)-year-old disabled Hispanic male living in a group home, alternating living as homeless.
CHIEF COMPLAINT: The patient was found wandering in the street saying that he wanted to kill himself by walking in front of the traffic.
HISTORY OF PRESENT ILLNESS: According to the patient, he has been feeling overwhelmed, was unable to sleep, sad, mainly due to pain in his back. The patient also reports that he had not been as compliant with his medication lately and that perhaps his medication is not working as well. The patient suffers from a seizure disorder. He suffers also from low back pain as a consequence of an accident. The patient says that two weeks ago, he had two seizures and those seizures hurt his back and since then it has hurt him “bad.” The patient goes to a group home, where he received Prozac 20 mg a.m. and trazodone 100 mg at bedtime.
The patient says he does take that medication but the main problem right now is his intense pain. He relates that his general practitioner has tried different types of medications in the past with no results in reducing the amount of pain. The patient, during the whole interview, did not speak about wanting to kill himself or desire to die. He just wanted relief of his pain. When asked, he says that if the pain continues like it has been, he prefers not to be alive. The suicidal intentions were very vague, and the patient was wandering in the streets for an hour or so and the police were able to speak to him and get him into a car. The patient denies any mood swing.
PAST PSYCHIATRIC HISTORY: The patient has the diagnosis of schizophrenia and a history of substance abuse. He has had multiple hospitalizations, multiple suicidal gestures, and suicidal attempts. None of them, admitted by the patient, had been serious. He knows that his life has been in danger. The patient had his first depression at the age of 15 when one of his sisters died.
SUBSTANCE ABUSE HISTORY: The patient stated that he started to drink when he was 16 and only stopped two years ago. He had a period of sobriety of three years that he had broken two days ago when he drank two beers. The patient uses marijuana several times a week. The patient denies the use of cocaine; although, there were traces of cocaine in his laboratory examination.
FAMILY HISTORY: The patient says that his sister suffered from depression and his father was an alcoholic.
PERSONAL HISTORY: The patient is one of six children. He says he had a good childhood with no history of emotional, physical, or sexual abuse. He was born and raised in (XX). The patient finished high school and then started to work for his father’s business, and he worked there until (XX), according to the patient, and then he started to have difficulty with depression and then he broke his back. Hence, the patient is now disabled. The patient is not active in any religion. According to the patient, he has no problem with the law. The patient says that he has never married. He has no children.
MENTAL STATUS EXAMINATION: Reveals a Hispanic male looking older than his stated age, disheveled with poor dental health. The patient has two or three tattoos in the forearms and wrist. He also showed scars from wrist fracture that had to be fixated surgically in his left arm. The patient’s affect was flat, but he was cooperative and showed some sad affect. Mood can be described as depressed. Speech: The patient spoke with some hoarseness, slow low tone, without extensive vocabulary. The patient’s main conversation was around his pain and the need of a medication that would take care of it. Thought content: The patient denies obsession or compulsions. The patient denies illusions or hallucinations. The patient admits to having some suicidal ideation with vague intention. Although he says that he was walking in front of the traffic, he was not hurt, and there was time for the police to convince him to come to the hospital. Sensorium: The patient was oriented to time, person, and space. The patient’s attention, concentration, and recall were poor. The patient seems to be of below average intelligence. The patient’s fund of general information is poor. The patient’s motivation for treatment is fair. The patient’s insight is poor. The patient shows good control of impulses.
DIAGNOSTIC IMPRESSION (DSM-IV):
Axis I:
1. Consider schizoaffective disorder.
2. Consider pain disorder.
3. Consider schizophrenia.
4. Consider substance abuse.
Axis II:
1. Consider mild mental retardation.
2. Personality disorder, deferred.
Axis III:
1. Chronic low back pain.
2. Hyperglycemia.
3. Mildly elevated liver enzymes.
Axis IV: Mild to moderate.
Axis V: Global Assessment of Functioning 60.
TREATMENT PLAN:
1. We will observe this patient overnight.
2. We will start the patient on Seroquel 50 mg at bedtime.
3. The patient will start receiving Prozac at 20 mg a.m.
4. Medical consultation has taken place and Percocet was prescribed at a dosage of 5/325 mg one tablet p.r.n.
