PATIENT SEEN TODAY FOR REGULAR APPPOINTMENT

PATIENT SEEN TODAY FOR REGULAR APPPOINTMENT. HE APPEARS RELAXED, COOPERATIVE, AND COHERENT. NO EVIDENCE OF RECURRENT MANIC BEHAVIOR. HE IS A 46-YEAR-OLD, DIVORCED TWICE, NAVY VETERAN, WHO SERVED AS A MACHINIST MATE IN NON-COMBAT SITUATION. HE HAS BEEN SUFFERING FROM BIPOLAR DISORDER, MANIC TYPE, AND TAKES MEDICATION, LITHIUM 1,500 MG A DAY, WHICH SEEMS EFFECTIVE. HE HAS BEEN EMPLOYED AT ALSTOM PLANT AS A MACHINIST FOR NINE YEARS, FULL TIME. MENTAL STATUS EXAM: HE HAS BEEN DOING VERY WELL WITH THE CURRENT MEDICATION. NO EVIDENCE OF MEMORY LOSS OR ANY PSYCHOTIC BEHAVIOR. HIS AFFECT IS APPROPRIATE, AND MOOD IS STABLE, INSIGHT AND JUDGEMENT ARE GOOD. HE IS NOT CONSIDERED A DANGER TO HIMSELF OR OTHERS. DIAGNOSIS: BIPOLAR DISORDER, MANIC TYPE. PLAN: CONTINUE LITHIUM 1,500 MG A DAY CODE USING ICD-10-CM AND CPT