General Practitioner-Vorlage
Hospital - Psychiatric Emergency Consultation (PEC)
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
The Hospital - Psychiatric Emergency Consultation (PEC) template is designed for General Practitioners handling psychiatric emergencies in a hospital setting. This comprehensive template assists clinicians in documenting patient details, medical history, current medications, and hospital progress. It also includes sections for reviewing consults, physical examination findings, and planning treatment strategies. The template ensures thorough documentation of psychiatric cases, aiding in accurate diagnosis and effective treatment planning. Ideal for use with Heidi, this template streamlines the documentation process, enhancing efficiency and accuracy in psychiatric emergency care.
Vorlagenvorschau
PEC - 3 West, Room 12
ID:
- 45, Female
- Level of Care B (discussed)
Reason for admission:
- Acute psychosis
Past Medical History:
- Hypertension, Type 2 Diabetes
Medication:
In hospital:
- Olanzapine 10mg daily
At home:
- Metformin 500mg twice daily
Allergies
- Penicillin
- From home
Review of Hospital Progress:
- Presented to the emergency department on 1 November 2024 with confusion and hallucinations. Triage noted elevated blood pressure and disorientation. Emergency physician's impression: acute psychosis.
- Psychiatry: Impression of acute psychosis, recommended initiation of antipsychotic medication.
- Neurology: No neurological deficits noted, ruled out seizure activity.
- 1 November 2024: Patient remains disoriented, hallucinations persist.
Today:
- Reports auditory hallucinations, disorganized thoughts.
OE:
Good General State, no distress, no work for breathing
Heart: normal S1, normal S2 with no murmurs
No LL Edema
Lungs: Normal Vesicular breathing, No crackles, No wheezing
Abdomen: Soft, no tenderness, no Rigidity, no Rebound, negative Mcburney sign
Investigations:
Review of Labs:
- no new labs
Review of Imaging:
- no new imaging
Impression/Plan:
45-year-old female presented with acute psychosis:
1. Acute Psychosis
- Impression: Acute Psychosis
- Differential diagnosis: Schizophrenia, Bipolar Disorder
- Investigations planned: MRI brain, EEG
- Treatment planned: Continue Olanzapine, monitor mental status
- Relevant referrals: Psychiatry follow-up
2. Hypertension
- Treatment planned: Monitor blood pressure, adjust antihypertensive medication as needed
3. Type 2 Diabetes
- Treatment planned: Continue Metformin, monitor blood glucose levels
4. Expected date of discharge
- To be determined based on psychiatric stabilization
5. Other:
- Prophylactic anti-coagulation: No
- Foley catheter: No
- GFR/Kidney function: GFR 85 mL/min
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