Duval, Larry. Discharge Summary
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- Preston Paul
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1 The Best Clinic High Bluff Dr, Suite 200 Arlington, TX Phone: Fax: :32:44 PM DATE ADMITTED: 4/20/2009 DATE DISCHARGED: This discharge summary consists of 1. The Initial Assessment, 2. Course of Treatment, 3. Clinician's Narrative, and 4. Discharge Status and Instructions 1. INITIAL PSYCHIATRIC ASSESSMENT 4/25/2009 Progress Note History: Larry has had no response to treatment yet.symptoms of depression continue to be described. They are unchanged in frequency and intensity. Symptoms occur a few times a week. When depressive mood occurs it typically lasts for hours. Appetite is unchanged. Larry reports that he continues to feel sad. Decreased sociability continues to be a problem. Wishes to be dead are expressed but suicidal ideas or intentions are convincingly denied. Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Feelings of anxiety are denied. He specifically denies manic symptoms. He denies obsessive, intrusive and persistent thoughts or compulsive, ritualistic acts. He describes no side effects and none are in evidence. Medical History: Current Medical Diagnoses: Asthma Current Medications (non psychotropics) include: Albuterol Adverse Drug Reactions: There is no known history of adverse drug reactions. Allergies : Shellfish (Hives) (Dyspnea) Primary Care Provider: Dr. P. Makikaiker (Family Practitioner)
2 Page 2 Medical history is otherwise negative and Larry has no other history of serious illness, injury, operation, or hospitalization. He does not have a history of seizure disorder, head injury, concussion or heart problems. No medications are currently taken. Mental Status: Larry is glum, minimally communicative, disheveled, and unhappy. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Signs of moderate depression are present. Larry sits and stares at the floor. Larry stares into the middle distance. Speech and thinking appear slowed by depressed mood. Facial expression and general demeanor reveal depressed mood. Wishes to be dead have been occurring but suicidal intentions are not present. Affect is appropriate, full range, and congruent with mood. There are no signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content is appropriate. Cognitive functioning was not formally tested today but appears clinically to be unchanged from previous examinations. Insight into illness is fair. There are no signs of anxiety. He is easily distracted. Axis I: Major Depressive Disorder, Single, Moderate /26/2009 Continued Celexa 20 mg PO QAM # 30 (thirty) X 1 Ira Morganstern, M.D. 2. COURSE OF TREATMENT 4/27/2009 Progress Note History: Larry is worse today. Symptoms of depression continue to be described. They have worsened and are more frequent or more intense. Depressive symptoms are episodically present. Symptoms occur daily. When depressive mood occurs it typically lasts for hours. Appetite is unchanged. Larry reports that he feels sadder. Social isolation has worsened. Feelings of worthlessness are described. Wishes to be dead are expressed but suicidal ideas or intentions are convincingly denied.
3 Page 3 Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: No anxiety is described. He specifically denies manic symptoms. He denies obsessive, intrusive and persistent thoughts or compulsive, ritualistic acts. No hallucinations, delusions, or other symptoms of psychotic process are reported. Good medication compliance is noted. His relationships with family and friends are reduced. His functioning at work is marginal. Patient reports a dry mouth. This is considered a probable side effect of medication. No other side effects are reported or in evidence. Mental Status: Larry is glum, minimally communicative, casually groomed, and unhappy. He exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Signs of moderate depression are present. Demeanor is glum. Thought content is depressed. He says, "I hate my life." Body posture and attitude convey an underlying depressed mood. Speech and thinking appear slowed by depressed mood. Facial expression and general demeanor reveal depressed mood. Affect is appropriate, full range, and congruent with mood. There are no signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content is appropriate. Cognitive functioning and fund of knowledge is intact and age appropriate. Short and long term memory are intact, as is ability to abstract and do arithmetic calculations. This patient is fully oriented. Insight into illness is fair. Social judgment is intact. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. Axis I: Major Depressive Disorder, Single, Moderate () Anxiety Disorder, NOS () Instructions / Recommendations / Plan: The risks and benefits of the recommended treatment were explained to Larry who understood and accepted them. #1) Increase Celexa 30 mg PO QAM # 45 (forty five) X 1 Return 1 week, or earlier if needed. Notes & Risk Factors: None
4 Page (Office Pt, Established) Time spent on patient: min Group Therapy Note Group Therapy Note Group Type: Focus: The focus of today s group was the subject of anger management. Group members were first encouraged to examine the ways anger has adversely effected their lives. Group members were then directed to share and explore methods for controlling anger and to strategize other methods. Present at today's session were the following: Four members of the group were present today. Therapist Intervention: Therapist facilitated discussion about behavior management techniques. Extrapolated to Life Involved all Group Kept Group Focused Appearance and Behavior: In today's session Larry appeared calm, communicative, and relaxed. His participation today was normal, with responses to others and sharing of personal experiences and feelings. A normal amount of physical activity was exhibited by Larry today. Larry spoke today about interpersonal problems. Larry spoke about problems arising from a low tolerance for frustration. Suicidal ideas or intentions are not in evidence and not expressed. Mental Status Exam: Today Larry appears depressed. His facial expression and body posture suggest an underlying depressed mood. His demeanor is sad. There are no signs of anxiety. There are no signs of hallucinations, delusions, a thought disorder or other signs of psychotic process. Larry s speech is normal in rate, volume and articulation and is coherent and spontaneous. Larry was attentive and focused in group today. Larry s associations are intact. No signs of cognitive loss are present. Plan: Continue group.
5 Page 5 Axis I: Major Depressive Disorder, Single, Moderate (Active) Anxiety Disorder, NOS (Active) Notes & Risk Factors: None Time spent on patient: min Progress Note History: Larry today denies any psychiatric problems or symptoms. His behavior has been appropriate and uneventful. No side effects are described or evident. Prob. Pert. ROS / Assoc. S&S: He specifically denies psychotic, depressive or anxiety symptoms. Mental Status: Mood is euthymic with no signs of depression or elevation. His speech reveals no abnormalities of rate, volume and articulation and his language skills are intact. He convincingly denies suicidal ideas. There are no assaultive or homicidal ideas or intentions. There are no signs of psychotic process. His behavior is not bizarre and there are no indications that hallucinations or delusions are present. There are no signs of a thought disorder. Associations are intact, thinking is generally logical and thought content appropriate. Cognitive functioning, based on vocabulary and fund of knowledge, is commensurate with his age and abilities. Orientation, memory and general cognitive abilities present as normal and intact.. No signs of anxiety are present. There are no signs of hyperactive or attentional difficulties. Insight and judgement are intact. Axis I: Major Depressive Disorder, Single, Moderate (Active) Anxiety Disorder, NOS (Active) 4/27/2009 Increased Celexa 30 mg PO QAM # 45 (forty five) X 1 Notes & Risk Factors: None
6 Page 6 This is the final note for this patient. Progress Note History: Larry today denies any psychiatric problems or symptoms. His behavior has been appropriate and uneventful. No side effects are described or evident. Prob. Pert. ROS / Assoc. S&S: He specifically denies psychotic, depressive or anxiety symptoms. Mental Status: Mood is euthymic with no signs of depression or elevation. His speech reveals no abnormalities of rate, volume and articulation and his language skills are intact. He convincingly denies suicidal ideas. There are no assaultive or homicidal ideas or intentions. There are no signs of psychotic process. His behavior is not bizarre and there are no indications that hallucinations or delusions are present. There are no signs of a thought disorder. Associations are intact, thinking is generally logical and thought content appropriate. Cognitive functioning, based on vocabulary and fund of knowledge, is commensurate with his age and abilities. Orientation, memory and general cognitive abilities present as normal and intact.. No signs of anxiety are present. There are no signs of hyperactive or attentional difficulties. Insight and judgement are intact. Axis I: Major Depressive Disorder, Single, Moderate (Active) Anxiety Disorder, NOS (Active) Axis II: None V71.09 Axis III: See Medical History Axis IV: None Axis V: 95 4/27/2009 Increased Celexa 30 mg PO QAM # 45 (forty five) X 1 Notes & Risk Factors: None This is the final note for this patient.
7 Page 7 3. CLINICIAN'S NARRATIVE See attached progress notes. Suggest do not change medications. 4. DISCHARGE STATUS AND INSTRUCTIONS Final Exam, Interval History Larry today denies any psychiatric problems or symptoms. His behavior has been appropriate and uneventful. No side effects are described or evident. Prob. Pert. ROS / Assoc. S&S: He specifically denies psychotic, depressive or anxiety symptoms. THERAPY CONTENT/CLINICAL SUMMARY Final Exam, Mental Status Exam Mood is euthymic with no signs of depression or elevation. His speech reveals no abnormalities of rate, volume and articulation and his language skills are intact. He convincingly denies suicidal ideas. There are no assaultive or homicidal ideas or intentions. There are no signs of psychotic process. His behavior is not bizarre and there are no indications that hallucinations or delusions are present. There are no signs of a thought disorder. Associations are intact, thinking is generally logical and thought content appropriate. Cognitive functioning, based on vocabulary and fund of knowledge, is commensurate with his age and abilities. Orientation, memory and general cognitive abilities present as normal and intact.. No signs of anxiety are present. There are no signs of hyperactive or attentional difficulties. Insight and judgement are intact Discharge Diagnosis Axis I: Major Depressive Disorder, Single, Moderate (Active) Anxiety Disorder, NOS (Active) Axis II: None V71.09 Axis III: See Medical History Axis IV: None Axis V: 95 Type of Discharge: Regular Condition on Discharge: Greatly improved Medications at Discharge:
8 Page 8 Celexa 30 mg PO QAM Medication Instructions: Patient was instructed to take medications as prescribed and was informed about potential side effects. Consent: Patient was advised regarding the risks and benefits of treatment. Physical Activity: No limitations on physical activity Dietary Instructions: Regular diet. Other Instructions: Follow through with safety plan at home and school as discussed Emergency Contact: Phone: Fax: Notes and Risk Factors: None
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