Psychiatric IP Follow-up Visit

Subjective:
History of Present Illness:
- Since the last encounter, the patient reports low energy, which the patient attributes to antipsychotic medication. The patient describes decreased motivation for previously enjoyed activities, such as playing basketball, and increased sleep, which the patient believes is due to environmental noise. The patient denies difficulty getting enjoyment out of things that normally bring joy, denies feelings of guilt or regret about the past, and denies difficulty starting movements or pacing around the room. The patient reports no belief that stopping medications would cause anything bad to happen. The patient reports no auditory or visual hallucinations currently and none last night. The patient expresses frustration about being in the hospital and acknowledges previous inconsistencies in symptom reporting.

Past Medical History:
No significant past medical history reported.

Social History:
- The patient does not report enjoyment in connecting with other people. No additional information regarding interactions with nursing staff, visitors, or peers, or involvement in hospital activities or therapy sessions is provided.

Current Medications:
- The patient is currently taking antipsychotic medications, including Risperidone and Clozapine. The patient reports that Risperidone was effective in stopping auditory hallucinations. The patient attributes low energy and depressed mood to Clozapine and expresses a desire to discontinue it. No allergies are reported.

Past Psychiatric History:
The patient has a history of psychotic symptoms, including auditory and visual hallucinations, previously managed with Risperidone. The patient reported that Risperidone was effective in resolving auditory hallucinations. The patient was subsequently prescribed Clozapine, after which the patient experienced a decline in mood and reported depressive symptoms. There is no history of previous psychiatric hospitalizations or other psychiatric diagnoses mentioned. Pertinent negatives include denial of prior depressive episodes, anhedonia, or suicidality prior to the current medication regimen.

Substance Use History:
No history of alcohol, tobacco, or illicit drug use was reported.

Objective:
Mental Status Examination:
- General Appearance: Not assessed.
- Behavior: Cooperative during the interview.
- Speech: Normal rate and rhythm.
- Mood: The patient describes mood as depressed, particularly after starting Clozapine.
- Affect: Not assessed.
- Thought Process: Logical and goal-directed.
- Thought Content: No delusions reported. No difficulty getting enjoyment out of things that normally bring joy. No feelings of guilt or regret about the past. No difficulty starting movements or pacing around the room. No enjoyment in connecting with other people.
- Perception: No auditory hallucinations currently. No visual hallucinations currently. No hallucinations last night.
- Insight/Judgment: The patient demonstrates some insight into medication effects but has inconsistencies in symptom reporting.

Assessment:
Safety Assessment:
- The patient denies thoughts of wanting to hurt oneself or insinuations. No acute safety risks identified during the encounter. No changes to the safety plan are indicated.

Problem:
- The patient demonstrates low energy and decreased motivation for activities, which the patient attributes to antipsychotic medication. The patient reports improvement in auditory hallucinations with Risperidone and attributes depressed mood to Clozapine. The patient denies current hallucinations and denies suicidal ideation. There is inconsistency in symptom reporting, raising concerns about reliability of self-report. The patient expresses frustration with hospitalization and desire for discharge.

DSM-5-TR Codes:
- F20.9 (Schizophrenia, unspecified)

Plan:
- Adjust current antipsychotic regimen by evaluating the potential discontinuation of Clozapine and considering alternative medications. - Emphasize the importance of accurate reporting of symptoms and medication effects during follow-up. - Assess medication efficacy and side effects during the next scheduled review. - Coordinate with the healthcare team to monitor the patient's progress and modify the treatment plan as necessary.

Progress and Outcomes:
- The patient reports no current hallucinations and attributes improvement to Risperidone. The patient continues to experience low energy and depressed mood, which the patient associates with Clozapine. The patient remains frustrated with hospitalization and expresses a desire for discharge. No acute safety concerns identified.