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After further review of this patient being seen in the emergency department for a traumatic incident, I agree with the following subject information, objective information, and treatment plan.

Patient: C.U.

Patient Demographics:

Age: 79 y.o

Sex: female

Race: African American  

Subject:

CC: distressed, delusional, confused, extreme fear and anxiety

History: 79-year-old female has been living at her independent living facility since 2010. She is fully functional and independent.  She provided care for five years for her husband who recently passed away six months ago. Her only relative is a daughter who talks with her about once a month.  Two days ago, her home was broken into, and she was raped and robbed. The housekeeper found her laying on the floor. She was down for two days and was taken to a local hospital.  Here, she is distressed, delusional, and is reported to be very emotionally distraught. There are no signs of broken bones or rhabdomyolysis

SHx: 

Marital Status: widowed

Children: one daughter

Occupation: retired school secretary

Living Quarters: independent living facility

Tobacco use: Denies

Alcohol use: Denies

Illicit drug use: Denies

PMHx: Chronic conditions are pernicious anemia, osteoarthritis, and urinary incontinence

PSHx:  hysterectomy

Allergies: penicillin

Current Medications:

Multivitamin one-a-day for women

Cyanocobalamin (vitamin B12) 1000mcg

Capsaicin topical cream 0.075%

ROS:

Systemic: Denies fever, chills, or recent weight gain

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