Problem:
Write an follow up PSYCH VISIT and post acute readmit, chief complaint, , Psychiatric visit HPI, current Psych meds, , diagnosis and recommended Plan (medication and dosages), rationale for using the medications for a 56years old female with severe tearfulness. Current Meds: Buspirone 5mg daily, Sertraline 12.5mg daily HPI: Assessment was done in the patient's room. She has physical diagnosis of CVA which is very recent. She is struggling with adjustment after the CVA. She struggles with expression but able to hold a conversation. She is working with speech therapy. She is working with physical therapy and occupational therapy. She uses a tube feeding 8pm to 8am. She eats orally during the day but struggles with poor appetite. She was tearful during the appointment. She said she sleeps ok but she is just sad. Patient is struggling to adapt and adjust after her medical condition She is not married and do not have kids. Lives with her Dad. The Recommended plan is to increase Sertraline 25mg to address . Add diagnosis depression as evidenced increased tearfulness. This provider called Patients Sister, Sally Soran who is the Patient's POA and discussed the recommended plan. POA gave verbal consents to the treatment plan . POA said she is a teacher and will spend her summer taking care of the client (Sister). Add diagnosis of adjustment disorder with mixed anxiety and depression Psychosocial: lived with father prior to CVA. Need Assignment Help?