Penn Foster Medical Transcription Graded Project

RE: Conservatorship, Elmer Edward Essing

I am writing you in regard to my psychiatric evaluation of the above-named individual, conducted at Sweetwater Home Board and Care on November 5, 2012.

I was requested by his wife to evaluate the patient psychiatrically because of the difficulty he has been experiencing recently in terms of confusion and agitated behavior. His wife asked me to evaluate him at Sweetwater as it is very difficult for her to transport the individual to my office because he is confused disoriented and at times hostile and belligerent.

According to the records, the patient is 69 years of age, has a history of rheumatic heart disease with mitral stenosis that is severe, C. H. F., afib, with history of multiple cerebral emboli that probably has caused senile dementia. He did not appear to recognize the purpose of the interview, nor did he appreciate the opportunity to present his view to the interviewer. He was able to state his name but was generally thoroughly hostile and openly oppositional and sarcastic during the interview. He refused to give me many details of his past history relating that I don’t need your help. The patient himself did not speak spontaneously; he tended to repeat over and over again that he did not need help, that all he needed was his wife to take him out of Sweetwater. He did not appear to be able to give me the current date, time, year or month, nor was he able to give his location in terms of city or state. He refused to answer most of my questions, but it was apparent that the patient at times tended to confabulate and avoided answering questions that he would have difficulty with by being openly hostile.

He had a very constricted effect that was at times labile, openly so, in anger and disgust. His mood was depressed, with some history of sleep disturbance, but he denied any suicidal ideation or any selfdestructive behavior periods.

(continued)

Date

RE: Conservatorship, Elmer Edward Essing

Page 2

Hypothesis: The patient had general difficulty completing thought trends. He denied any hallucinations or delusions, but his guardedness would indicate possible paranoid ideation with possible unsystemized persecutory delusional system. He felt there was some type of conspiracy against him to place him at Sweetwater Home Board and Care. He was unable to recognize and appreciate his medical and mental circumstances appropriately and respond to them in an appropriate manner. Judgement was impaired since the patient could not make medical or financial decisions in his best interest. I do not feel that he knows the extent of his medical illness or his financial situation. The patient was disoriented to time, person and place.

IMPRESSION: Organic brain syndrome, probably secondary to multiple cerebral embolus from history of rheumatic H.D. and atrial fibrillation.

At this point in time, I feel that the patient is gravely disabled, that he cannot provide food, shelter, or clothing for himself nor make decisions in regard3 to his medical or financial affairs in his best interest.

I recommend that he be continued in a structured living situation with supervision of medication and recommend conservatorship of person and property.

If further information is needed, please feel free to contact me at any time.

Sincerely

Philip B. Michaelson, MD

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