this is my psychiatrist note from last admission , he was also the psychiatrist responsible for giving me 13 injections.
Chief Complaint
This is a 26 years old male who is well-known to myself. The initial assessment by the medical student was reviewed with thanks. I spoke to him and I spoke with his sister with his consent.
History of Present Illness
Patient reported that he does not like the way his family is interacting with him. They make him to get upset easily. He denied hearing voices or seeing things that are not there. He denied thought interference in terms of people putting thoughts into his head, taking thoughts out of his head or reading his mind. Denied any conspiracy going on. Denied suicidal ideation and homicidal ideation or intention. No evidence to suggest anxiety disorder. He denied the use of alcohol or illicit drug.
Mental status examination: He developed good rapport and good eye contact. Speech was coherent and spontaneous with with a normal tone, volume and rate. Mood is subjectively and objectively euthymic. No thought or perceptual abnormality present. He was oriented in time, place and present. He has a reasonable insight.
I spoke to his sister on the phone with his consent. She expressed concern about his impulsive behavior of recent. She gave an example when he went into Starbucks store and took pictures of people and wanted to post it on the social media because he thought that we should be boycotting American product. Having said that, she is happy for him to be discharged home and will follow up with his psychiatrist.
Plan:: Supportive therapy given. He will be discharged and follow-up with his psychiatrist in the community. He knows how to seek help in crisis. He denied the use of alcohol or illicit drug
Assessment/Plan
Ordered :Discharge Patient
