Médecin généraliste Template

Hospital - Psychiatric Emergency Consultation (PEC)

A professional Médecin généraliste template for healthcare professionals.

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Médecin généraliste

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8 times

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Note

Last edited

2026-03-09

Created by

Shady Abid

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About this template

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.

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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