Mr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer Unit. He was recently taken by his family for evaluation in the Emergency Department after he was found to be confused, physically aggressive with family members, threatening to burn the house down, and paranoid that someone was trying to kill him. The medical work up in the ED was unremarkable. He was discharged from the ED and since arriving at the facility, he has been verbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He does not answer most questions when asked by staff and appears agitated. Psychiatry is consulted for management of his behavioral and psychological symptoms.
Medical History: Diagnosed with Alzheimer’s Disease 2 years ago (diagnosed based on symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)
Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on the weekends x 10 years. Married. Previously employed as accountant
Family History: No history of dementia or mental health disorders. Mother deceased from colon cancer. Father deceased from MI. Son is 31 and healthy.
Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS
Physical Exam Notes
Constitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused. Inattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.
Head: Normocephalic, atraumatic
Cardiac: RRR, no murmurs noted
Lungs: CTA A/P
Abdomen: BS x active x 4, soft/non-tender, LBM 2 days ago
Musculoskeletal: Moves all extremities, abnormal/unsteady gait
Neuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete testing. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to complete MMSE.
Vitals: T: 98.8, P 88, R 18, BP 132/78)
Please follow directions and answer the questions outlined in the Unit 4 Assignment 2 area of your classroom.3
SOAP Note Template
Use the soap note templet supplied.
Patient Name: XXX
Date of Service: 01-27-2020
Start Time: 10:00 End Time: 10:54
Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)
Accompanied by: Brother
CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago
HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
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