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Patient Psychiatric Analysis

Decent Essays
I am writing you in regards to my psychiatric evaluation of the above-named individual, conducted at Sweetwater Home Board and Care on November 5, 2012. I was requested by his wife to evaluate the patient psychiatrically because of the difficulty he has been experiencing recently in terms of confusion and agitated behavior. His wife asked me to evaluate him at Sweetwater as it is very difficult for her to transport the individual to my office because he is confused diso-riented and at times hostile and belligerent. According to the records, the patient is 69 years of age, has a history of rheumatic heart disease with mitral stenosis that is severe, C. H. F., Atrial Fibrilation, with history of multiple cerebral emboli that proba-bly has caused…show more content…
His mood was depressed, with some history of sleep disturbance, but he denied any suicidal ideation or any self-destructive behavior periods. HYPOTHESIS: The patient had general difficulty completing thought trends. He denied any hallu-cinations or delusions, but his guardedness would indicate possible paranoid ideation with possible unsys-temized persecutory delusional system. He felt there was some type of conspiracy against him to place him at Sweetwater Home Board and Care. He was unable to recognize and appreciate his medical and mental cir-cumstances appropriately and respond to them in an appropriate manner. Judgement was impaired since the patient could not make medical or financial decisions in his best interest. I do not feel that he knows the ex-tent of his medical illnesses or his financial situation. The patient was disoriented to time, person and place. IMPRESSION: Organic brain syndrome, probably secondary to multiple cerebral embolus from his-tory of rheumatic H.D. and atrial fibrillation. At this point in time, I feel that the patient is gravely disabled, that he cannot provide food, shelter, or clothing for himself nor make decisions in regard3 to his medical or financial affairs in his best
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