Who consents to telehealth visit to establish care

Reference no: EM133730092

Subjective -Mr. EV is a 28 year old male who consents to telehealth visit to establish care. Patient was recently hospitalized at Palmetto General Hospital with psychosis on 04/24/2023. Patient states he cannot recollect he previous hospitalizations. States he is surprised and does not understand why his mother and girlfriend are saying he is not acting like his former self as believes he feels great with the current medication. States his mind is clear and he is able to function without any issues or difficulty with the medication. He does note that trazodone is not effectively as he is still having difficulty initiating sleep. States he takes the medication at 10 PM and falls asleep around 12 PM. He currently denies hearing/seeing any vocies or external stimuli not seen by other people. Patient denies any suicidal/homicidal ideations plan or intent, chest pain, palpitations, shortness of breath, dizziness, nausea, fever, involuntary muscle contractions, muscle rigidity, vomiting, and diarrhea.

Objective -

Constitutional: Oriented to person, place, and time. Appears well-developed and well-nourished. No distress.

Neurological/Psychiatric: General/Orientation: Awake, alert and oriented x3. No acute distress. Appearance, general attitude and behavior: Appears stated age. Combed hair. Fair hygiene. Casually dressed. Cooperative and calm. Fair eye contact Abnormal Movements/Gait: No psychomotor agitation or retardation noted. Stable gait. Characteristic and/or quality of speech: Normal rate, rhythm and tone. Mood and Affect: Reduced emotional responsiveness, Blunted Thought Process: Linear and goal oriented Thought Content: No delusions elicited; appropriate to topic Perceptual Disturbances: Denied auditory or visual hallucinations. Suicidal ideations/Homicidal ideations: Denied suicidal / homicidal ideations, intent or plan Memory: Grossly intact Attention/Concentration: Fair/Fair Insight and Judgement: poor/poor Medication Side Effects: Patient denied. None observed

Reference no: EM133730092

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