PROGRESS NOTE - INPATIENT - EMR for Psychiatry

Hospitality Care Skilled Nursing Center
1212 Anystreet

Miami, Florida 33163
Telephone (305) 555-1212
Facsimile (305) 555-1212

PROGRESS NOTE - INPATIENT

PATIENT NAME James Test MEDICAL RECORD NO. 4769
SOCIAL SECURITY 999-99-9999 SECONDARY MRN 0
DATE OF BIRTH May 09 , 1942 PROVIDER NAME Louis Test, M.D.
VISIT DATE August 13 , 2013

IDENTIFICATION This is a 71 year old white widowed male who resides in Miami Beach, Florida.
CHIEF COMPLAINT Mr. Test has been displaying inappropriate behavior.
BEHAVIOR INCIDENT Mr Test has experienced the following behavior incidences:
15 incidents reported of arguing and fighting with male residents.
CURRENT HISTORY 14 incidents reported of inappropriate sexual behavior.
Mr. Test was interviewed with his nursing home staff, whose reliability is considered good.
ANXIETY: He denied any anxiety symptoms.
APPETITE: He denied appetite change.
BEHAVIOR: James' behavior is reported as: intimidates others, the duration is reported as > 6
months, crying, the duration is reported as > 2 weeks and often initiate physical fights, duration is
reported as > 2 weeks.

COMPULSIVE BEHAVIOR: He denied compulsive behaviors.

CONCENTRATION: He denied disturbance of concentration.

DELUSIONS: He denied delusions.

ENERGY: James reports a high energy level.

HALLUCINATIONS: He denied any kind of hallucinations.

HARM TO SELF: He denied any self mutilating behavior.

HOMICIDE: He denied any homicidal thoughts, intent or plan.

MEMORY: James reports the following memory disturbances: impaired immediate. His
disturbances began or have been occurring for 6 months.
MOOD: James presents with a history of a manic mood type. His associated symptoms include
elevated mood, irritable mood and grandiosity. He reports the duration has been for > 6 months.
His symptoms are of a moderate rated intensity level.

OBSESSIVE THOUGHTS: James presents with a present history of a sexual obsession type. His
associated symptoms include forbidden or perverse sexual thoughts, images or impulses and sexual
behavior towards others (aggressive). His symptoms are of a moderate rated intensity level.

SLEEP: He denied any sleep change.

SUICIDE: He denied suicidal thoughts, intent or plan.

CLINICAL DEMENSIA SCALE COMMUNITY: No pretense of independent function outside home. Appears well enough to be
taken to functions outside a family home. Severity: Moderate.
HOME: Only simple chores preserved; very restricted interests, poorly maintained. Severity:
Moderate.
JUDGMENT: Severely impaired in handling problems, similarities, and differences; social
judgment usually impaired. Severity: Moderate.

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JAMES TEST Medical Record No. 0 Date of Birth: 05/09/1942 Encounter Date August 13, 2013

MEMORY: Moderate memory loss; more marked for recent events; defect interferes with
everyday activities. Severity: Mild.

ORIENTATION: Moderate difficulty with time relationships; oriented for place at examination;
may have geographic disorientation elsewhere. Severity: Mild.

PERSONAL: Requires assistance in dressing, hygiene, keeping of personal effects. Severity:
Moderate.

CDR SCORE: 10.

CDR INTERPRETATION: Moderate dementia.

CURRENT MEDICATIONS Mr. Test's current medications are:
IMIPRAMINE HYDROCHLORIDE TABLET 10 Quantity 1 IMIPRAMINE HYDROCHLORIDE
PAST HISTORY OF TABLET 10 MG QD for 30 Days. Prescribed by Louis Test, M.D.
MEDICATIONS
ALLERGIES ASPIRIN Advil.
His reaction is headache.
PETS Dogs.
His reaction is itching.

MEDICAL REVIEW OF A review of Breast, Cardiovascular, Constitutional, Endocrine, ENT, Eyes, Gastrointestinal,
SYSTEMS Genitourinary, Hematologic Lymphatic, Integumentary, Musculoskeletal, Neurological, Pain,
Respiratory medical systems was otherwise non-contributory.

VITALS HEIGHT 6 feet 2 inches

WEIGHT 203 lbs. Previous weight on 10/16/2013: 199 lbs.

BODY MASS INDEX 25.95
BODY SURFACE AREA 2.23

IDEAL WEIGHT CALC 175.92

OBESITY TYPE Overweight

BLOOD PRESSURE 122/68 Location - Right Arm and Position - sitting

TEMPERATURE 96.7 F
HEART RATE 58 beat per minute. Location - Right Arm

MENTAL STATUS Mr. Test is a 71 year old white male.
PATIENT APPEARS: appears to be younger than stated age.

REMARKABLE FEATURES: none.

ALERTNESS: alert.

APPEARANCE: well groomed, sexually provacative.

NUTRITIONAL STATUS: well nourished.
HABITUS: average height.

OREINTATION: person(name), place, time, situation.

EYE CONTACT: good.

SPEECH: hyperverbal.

VOICE: loud.
ATTITUDE AND BEHAVIOR: engagable, preoccupied.

MOOD: euphoric, anxious, irritable, i am doing lot better.
AFFECT: anxious, congurent with mood.

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JAMES TEST Medical Record No. 0 Date of Birth: 05/09/1942 Encounter Date August 13, 2013

DIAGNOSIS THOUGHT PROCESS: tangential.
ASSOCIATIONS: tangential.
THOUGHT CONTENT: preoccupations.
HALLUCINATION: He is not experiencing hallucinations.
DELUSIONS: He is experiencing grandiose delusions.
INTELLIGENCE LEVEL: high normal.
INSIGHT: fair.
JUDGMENT: fair.
FUND OF KNOWLEDGE: mildly impaired.
PROVERB INTERPRETATION: bizarre.
SIMILARITIES: unwilling to attempt.
SUICIDAL IDEATION: Mr. Test denies the presence of suicidal ideation.
HOMICIDAL IDEATION: Mr. Test denies the presence of homicidal ideation.

AXIS I: 296.31 - Major Depressive Disorder, Recurrent, Mild; 294.11 - Dementia due to
Klüver-Bucy syndrome, with behavioral disturbance.
AXIS II: Diagnosis Deferred on Axis II - 799.9.
AXIS III: deferred to the primary physician.
AXIS IV: James' current stressors include social environment and housing. The stress level of these
stressors is reported as of moderate intensity.
AXIS V: CURRENT GAF 51; HIGHEST PAST YEAR GAF: 59.

PLAN AND RECOMMENDATIONS

Any of our recommendations are subject to the approval of the IDCPT (Interdisciplinary Care Plan Team) and please fax or call the
primary care physician for his/her approval

MEDICATION ORDERS PRESCRIPTIONS
Mr. Test Prescription orders are:
LABORATORY-TESTS * Initial 1 MG LEUPROLIDE ACETATE INJECTION INJECTION, SOLUTION ORAL
FOLLOW-UP Quantity 1 LEUPROLIDE ACETATE INJECTION 1 MG/.2ML MG/.2ML QAM for 30 Days
Refills: 0 Dispense: 30.

ACTIVE MEDICATIONS
Patient is instructed to continue the following medications as directed:
* 10 MG IMIPRAMINE HYDROCHLORIDE TABLET Quantity 1 IMIPRAMINE
HYDROCHLORIDE TABLET 10 MG QD for 30 Days. Ordered by Louis Test, M.D.

2 weeks for further neurological testing and monitor medications.

PHYSICIAN SIGNATURE

Louis Test, M.D.

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JAMES TEST Medical Record No. 0 Date of Birth: 05/09/1942 Encounter Date August 13, 2013