Medical Transcription Sample Reports

Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Psychiatric (Psych) Evaluation Medical Transcription Sample

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Psychiatric evaluation regarding hallucinations and decision-making ability.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic female, who apparently has been living by herself for the last four weeks after she moved here from another city. The patient was brought to the emergency room with a chief complaint of having a frontal headache for two weeks. Per EMS, the patient had a hard time getting worked up since the day prior with alleged history of seven transient ischemic attacks. The patient also took two OxyContin in the morning before arrival to the hospital. The emergency room note states that the patient complained of confusion, symptoms had been noticed since the last few days, according to the son. The patient has history of recurrent falls, hitting her head the day prior to arrival to the hospital, not experiencing any known loss of consciousness. She has a history of having expressive aphasia since Friday. She also had tendency to take too many of her pain medications, according to her son, obtained in the emergency room note. Today, on assessment, the patient is quite confused, sitting on a chair, very tangential and quite delusional regarding family members, thinking they are plotting against her. She keeps confusing her grandchildren, stating that they are her great grandchildren and talking about unrelated topics. In addition, she has been acting erratically, pulling intravenous lines, noncooperative, refusing to eat or drink. On our assessment today, the patient persists with a very delusional thought process, appears to be hallucinating as well at times, and confused, although she presents at times oriented to place and time. Oriented fairly well to person; however, unable to give account for why she is in the hospital without going into tangential thoughts. According to family members and collateral information, she does not suffer from dementia; although, there have been some mild cognitive changes, perhaps associated with age.

PAST PSYCHIATRIC HISTORY:  Unremarkable, although she has been taking citalopram 20 mg a day. There is no known history of psychiatric hospitalizations or suicide attempts.

SUBSTANCE ABUSE HISTORY:  No reported alcohol, drug abuse or tobacco use at this point.

PAST MEDICAL HISTORY:  History of hypertension, cervical spine surgery, laminectomy, hysterectomy, hip fracture and surgery, history of recurrent falls, multiple transient ischemic attacks, thyroid problems.

HOME MEDICATIONS:  Include Celexa 20 mg, Lasix at bedtime, aspirin 81 mg 2 at bedtime, Zocor 40 mg at bedtime, lisinopril 40 mg daily, oxycodone 2 tablets 5/325 as needed every 6 hours, OxyContin 40 mg twice a day, diazepam 5 mg, morphine which apparently she stopped. This is according to the medication list that the patient brought.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient has been living alone over the last 4 weeks.

MENTAL STATUS EXAMINATION:  The patient is a Hispanic female, sitting in the chair, in the room, seen with family present. She is alert and oriented to person, partially to place, not oriented to time. Quite confused, delusional, and admits to hearing things, hallucinatory at times. She presents paranoid with tangential thought process and quite delusional; however, does not endorse suicidal or homicidal ideations or plans. No abnormal movements observed. She has been refusing to eat and drink. Pulled intravenous lines earlier.  Attention span is decreased and so is her concentration. Unable to formally test for mini-mental status examination yet, quite compromised at this point.

ASSESSMENT:
AXIS I:  Agitated delirium, etiology to be determined, most likely multifactorial, possibly including metabolic, infectious, underlying neurological issues, medications toxic effects or withdrawals.
AXIS II:  Deferred.
AXIS III:  Chronic pain syndrome, hypertension, thyroid problems, recurrent falls, failure to thrive with risk for malnutrition.

LABORATORY WORKUP:
Today shows sodium 138, potassium 4.1, chloride 102, CO2 of 24, glucose 106, BUN 20, creatinine 0.9, calcium 8.9, protein 6.3, albumin 2.9, total bilirubin 0.32, ALT 24, AST 13, GFR more than 16. Complete blood count normal. White blood count 9000, hemoglobin 11.6, hematocrit 35.2.

RECOMMENDATIONS:
At this point, the patient presents with severe altered mental status, delusional, hallucinating, confused, unable to process information provided to make informed decisions about her care. She will benefit from help to make her decisions on her behalf due to her current underlying mental condition. I have reviewed her findings and my opinion. Also answered the questions of family members and discussed with them the risks, benefits, and potential adverse effects of risperidone. Family is in agreement to use risperidone for delirium and improved thought process. Provided supportive therapy with reassurance. Will recommend maintaining pain management. Consider perhaps switching from morphine to other agents that might be less confusing, and manage constipation as well. We will follow the case as necessary. At this point, given her underlying condition, it might be appropriate to continue management in the hospital before stepping down to a skilled nursing facility level of care.

Thank you, Dr. Doe, for allowing me to participate in the care of this patient.


Mental Status Examples                              Psychiatric Discharge Summary Sample