DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
IDENTIFICATION AND HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male who was admitted for placement of Hickman catheter. The patient has a diagnosis of aplastic anemia, and he is transfusion dependent. We were asked to see the patient as he has a history of panic attacks and anxiety. The patient states that he used to have panic attacks and that he has been taking Xanax over the last year and a half, and it has helped him tremendously. He is not having any more panic attacks. He does feel anxious at times. The patient’s mood was depressed, talking in a slow soft voice. He was dozing off as he was on pain medication but was able to stay alert and answer questions.
He denied auditory or visual hallucinations. He denied any thoughts of hurting himself or anyone else. He states that he feels sad at times but does not want to give up. He wants to have transplant. He wants to live for his family. The patient states that he is a family oriented man. He enjoys being with his 14-year-old son. He likes to watch sports. He denies use of alcohol or illicit substances.
PAST PSYCHIATRIC HISTORY: Significant for outpatient treatment. The patient was unable to name his psychiatrist but states that he has been taking Xanax for the last two years. He has not been on any other psychotropic medications. He denies any previous suicide attempts or any previous inpatient hospitalizations.
FAMILY HISTORY: The patient lives at home with his wife. They have been married for 15 years and have a 14-year-old son. He denies any family history of psychiatric problems, except that one of his cousins has anxiety.
LEGAL HISTORY: He denies any legal problems.
SUBSTANCE ABUSE HISTORY: He denies use of alcohol or illicit substances.
EMPLOYMENT HISTORY: The patient has not been able to work in the last several years.
PAST MEDICAL HISTORY: Significant for aplastic anemia. He had MRSA infection in the past.
ALLERGIES: No known drug allergies.
MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old African-American male who is lying in bed. He is alert and oriented to time, place, and person. His mood was depressed with flat affect and was talking in a slow soft voice. He gave straight answers. He denied auditory or visual hallucinations. He denied homicidal or suicidal ideations. Insight and judgment fair. He appears to be of average intelligence. His memory for recent and remote events is slightly impaired.
IMPRESSION: The patient appears to be depressed, withdrawn, and has a history of panic disorder, which has been under fair control.
DIAGNOSES:
Axis I:
1. Panic disorder without agoraphobia.
2. Depressive disorder, rule out general anxiety disorder.
Axis II: No diagnosis.
Axis III: As per medical history.
Axis IV: Medical issues.
Axis V: Current Global Assessment of Functioning 45.
RECOMMENDATIONS: We would recommend continuing him on the Xanax, even though it is a high dose; it has controlled his symptoms. We will add Lexapro 10 mg a day. Once he has a stable dose of Lexapro, his Xanax should be slowly weaned.
Thank you very much for letting us participate in the care of this patient.
