DATE OF CONSULTATION: MM/DD/YYYY
CONSULTING PHYSICIAN: John Doe , MD
REQUESTING PHYSICIAN: Jane Doe , MD
IDENTIFICATION DATA/REASON FOR CONSULTATION: The patient is a (XX)-year-old male who is admitted for assessment and treatment of alcohol problem and depression. Current assessment is requested to review and recommend on his psychological symptoms.
SOURCES OF INFORMATION: Include face-to-face interview with the patient, collateral information from review of the chart, and the patient's wife who is present at the bedside.
CHIEF COMPLAINT: The patient reports, "I have been feeling depressed, under stress, drinking more alcohol lately."
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who claims to have some stress and not having support from the family, etc. Apparently, under the stress, he has more anxiety, more depression and started drinking more alcohol. He claims to have been drinking pretty regularly over the past couple of weeks though he started drinking more about a couple of months ago, almost up to a pint a day of vodka. Apparently, he does have some withdrawal symptoms in the morning and started drinking again. He reports of no legal problems, no medical problems, no family problems because of the alcohol. He apparently was living in a hotel on Wednesday night under the influence of alcohol. He felt very depressed and thought of jumping off of the balcony. At that time, he felt uncomfortable and asked his wife to bring him to the hospital. The last use of alcohol is Wednesday night. He reports of mild tremulousness but otherwise no hallucinations, no sweating, no paranoia. He reports of no current suicidal ideation or plans. He denies of hallucinations. He admits to trouble with sleep at night. He claims to have good appetite. He reports feeling sad, some crying episodes. He denies irritability or racing thoughts. He denies other illicit drug abuse. He denies any panic attacks. He does admit to some trouble with attention span for many years. Claims the symptoms of alcohol abuse and also depressive symptoms were gradually getting worse over the past couple of months. He expressed his intent to seek help on outpatient basis.
PAST PSYCHIATRIC HISTORY: The patient has no prior psychiatric hospitalizations, suicide attempts or assaults on others but admits to taking antidepressant medications such as Paxil and Xanax many years ago for depressive symptoms. He reports that Paxil did not work on him but Xanax did work on him good but also caused excessive sedation, which he did not like. No history of illicit drug use. History of alcohol problem off and on, alcohol use from age (XX) though he reports drinking only during the weekends and socially. Only in the past few months, he reports of alcohol getting over his usual limits. Reports of smoking half a pack of cigarettes per day.
ALLERGIES: NONE KNOWN.
PAST MEDICAL AND SURGICAL HISTORY: He has a diagnosis of psoriasis. No history of surgeries.
CURRENT MEDICATIONS: Multivitamin and Protonix.
SOCIAL/PERSONAL HISTORY: He is a married male who reports of one child. He claims to have been married for (XX) years. He reports of some college education.
FAMILY HISTORY: Negative.
REVIEW OF SYSTEMS: He reports of no chest pain, no shortness of breath, no headache, no blurred vision, no nausea, no fever, no chills, no constipation, no diarrhea. He does admit to mild tremulousness of the upper extremity.
PHYSICAL EXAMINATION: Reviewed the vital signs from the chart.
MENTAL STATUS EXAMINATION: The patient is an average-built male who is dressed in a hospital gown, sitting in bed, in no acute physical distress. No involuntary movements noted though at times fine tremors of the hands were noticed. No agitation is noticed. Psychomotor activity within normal limits. Speech and language functions are intact and adequate. State of mood, he feels depressed. Affect is appropriate. Good range of emotions noted, depressed. Thought process is linear and coherent. Thought content shows recurrent psychotic symptoms. No suicidal ideation or plans. No homicidal ideation or plans. The patient denies of hallucinations and does not appear to be reacting to internal stimuli. Cognitive functions are intact for orientation to place, person, day. Memory is intact to remote, recent, and immediate recall. General fund of information is average. Intellectually appeared average. Insight and judgment good.
LABORATORY DATA: The patient's chart was reviewed for laboratory test results, which showed urine drug screen positive for marijuana. Glucose level at 122. Serum chemistries otherwise negative. Alcohol level less than 13.
SUMMARY: This is a (XX)-year-old male with history of alcohol abuse and possible marijuana abuse, who presents with depressive symptoms over the past 2 months due to multiple psychosocial stressors. No significant family history.
MEDICAL DECISION MAKING AND OTHER DIAGNOSES:
Axis I:
1. Major depressive disorder, recurrent, moderate.
2. Alcohol abuse.
3. Cannabis abuse.
Axis II: Deferred.
Axis III: Per past medical history.
Axis IV: Stress and problems with medical conditions, other psychosocial stressors.
Axis V: Current Global Assessment of Functioning of 70-75.
RECOMMENDATIONS AND PLAN: After psychiatric assessment was completed, the diagnostic impression and proposed treatment plans were reviewed with the patient. No imminent danger to self or others currently. He is willing to seek help on outpatient basis for depression and also alcohol problems. He seeks to stay sober. He has no current suicidal ideation or plans. No homicidal ideation or plans. The risks, benefits, side effect profile and alternatives were discussed with the patient and his wife with regard to treatment with antidepressant medications such as either Wellbutrin or Lexapro. The patient chose to take Lexapro. The patient agreed to take the medication as recommended. Prescription for 30-day supply was given to the patient and left in the chart. The patient can be discharged to home from psychiatric point of view. I do not see any reason for the patient to be monitored one-to-one at present. Continue medical management as appropriate. The patient can be discharged from psychiatric point of view once medically stable and cleared.
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