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Diagnosis and recommended plan for old male


Problem: Write an follow up PSYCH VISIT, chief complaint, Psychiatric visit HPI, current Psych meds, exam, diagnosis and recommended Plan for an years 65years old male who resides at a skilled facility currently seen today for a follow up visit . Patient was seen due to notification letter from patient health and safety concerns. The concerns stated that the patient is receiving three or more CNS-active medications based on his records. These medications are Quetiapine 50mg daily, Bupropion 75mg in the morning for MDD, Bupropion 37.5mg at HS for MDD, Gabapentin 100mg TID, LEVEtiracetam 500mg at for seizures, methocarbamol 500mg PRN every 6hours. Based on the Beers Criteria, CNS polypharmacy with agents such as muscle relaxants and opioids should be avoided. This provider contacted the medical director of the facility and based on patient;s administration records, he only receives the Methocarbol 500mg PRN for muscle spasm like once in 1-2weeks. This provider and the medical drector agreed to d/c methocarbamol. The plan is to d/c the methocarbol, Reduce quetiapine dose to 25mg daily, d/c Bupropion 37.5mg at HS. The patient was also seen in his room this morning but he did not want to participate in the assessment, he said he just wamted to sleep more and not be bothered. Staff reported he has been compliance with treatment with rare outburst. He has a history of epilepsy unspecified, alcohol withdrawal, alcohol dependence complicated and MDD. Need Assignment Help

 

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