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Psychiatry - Psychiatric Assessment Medical Transcription Transcribed Sample

IDENTIFICATION:  This is a (XX)-year-old single male.

PRESENTING COMPLAINTS:  The patient reported history of agitation and stress as well as depression.

HISTORY OF PRESENT ILLNESS:  The patient denied any significant history of medical problems whatsoever.  He reported having psychiatric problems since his childhood.  He stated that he had a very difficult childhood.  His mother was only (XX) years old when she gave birth to him.  She was not really there to take care of him.  She was partying most of the time.  She was drinking as well and was physically abusive towards him.  The patient stated that he was abused by his stepfather and mother physically.  He denied any history of sexual abuse.  He stated that he had a chaotic upbringing at home and really became depressed.  He was exposed to crime at an early age and had been incarcerated in juvenile facilities as well.  The patient reported that in (XXXX) he was incarcerated in a juvenile facility when, because of the home stress, he tried to hang himself.  He was depressed at that time.  He stated that he was diagnosed with depression and hyperactivity and in the past had been treated with medications, including Ritalin and Zyprexa.  He denied any other history of suicide attempts.  He denied any history of auditory or visual hallucinations whatsoever.  He reported that he had never been admitted to a psychiatric facility in the past.

At the time of assessment, the patient reported that he had been receiving treatment for depression.  He stated that he had been depressed for a long time.  He stated that his depression was basically partly agitation, stress, as well as sad mood.  He stated that in (XXXX) he became agitated to the point that he started cutting on his arm.  The patient reported that he was seen by the psychiatrist and was started on lithium for agitation.  He reported that his condition improved significantly.  The stress had subsided since then.

At the time of evaluation, the patient reported that he was doing fairly well with lithium.  He reported that he did not need Vistaril.  He had been resting well.  He had been eating okay.  He denied any depressed mood.  Denied any suicidal or homicidal ideation.  He denied any auditory or visual hallucinations.  He reported that he felt much better and wanted to continue taking lithium carbonate.  He stated that in future, if he continues to do well, he would consider trying to get off of the medication, if at all possible.  He did not report any side effects of the medications.  He stated that his mood was very stable and did not have any mood swings, periods of agitation or anger.  He did not report any past history of mood swings, which were consistent with mania or hypomanic episodes whatsoever.  He did not report any symptoms, which were consistent with psychosis in the past.

PAST MEDICAL HISTORY:  As discussed above.

PAST PSYCHIATRIC HISTORY:  As discussed above.

PERSONAL HISTORY:  The patient was single.  Did not have any children.

ALLERGIES:  He was not allergic to anything.

FAMILY HISTORY:  The patient denied any significant history of medical or psychiatric problems in the family.  There was no history of suicide.

SUBSTANCE ABUSE HISTORY:  The patient reported that he started drinking at the age of (XX).  At his peak, he was drinking every other day.  He denied any history of DUIs or public intoxication charges.  He was 0/4 on CAGE questions.  The patient admitted to having smoked embalming fluid.  He had abused cocaine in the past by snorting.  He stated that he started using drugs at the age of (XX).  At his peak, he was using 3 grams of cocaine by snorting every day.  His last use was in (XXXX).  He did not report any cravings, withdrawals or any other desire to take any drugs.  He did not report any intravenous drug abuse whatsoever.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male sitting on a chair.  He was alert, oriented, and cooperative.  Concentration and memory intact.  Speech was normal in rate, flow, and tone.  Language was appropriate and goal directed.  Mood was euthymic.  Affect was full.  No suicidal or homicidal ideation, auditory or visual hallucinations or delusions.  No flight of ideas, loosening of association, tangentiality, or circumstantiality.  He seemed to have good insight into his situation.  His judgment was intact. 

DIAGNOSES:

Axis I:             1.  History of adjustment disorder with mixed emotions.
                        2.  Alcohol abuse.
                        3.  Polysubstance abuse. 

Axis II:           Antisocial personality disorder, primary diagnosis.

Axis III:          Deferred.

Axis IV:          Legal problems.

Axis V:           Global Assessment of Functioning 70-75 at the time of assessment.

TREATMENT PLAN:  The patient was seen in detail.  He was educated about symptoms of mental illness and available resources. Risks, benefits, and side effects of the medication lithium were discussed including dry mouth, constipation, blurring of vision, tremors, risk of toxicity, risk of toxicity with different medications including nonsteroidals as well as salt restriction and dehydration.  He was informed in detail about risk of diabetes insipidus, hypothyroidism, kidney damage as well as other organ effects.  He was able to ask questions.  He was able to discuss the side effects in detail.  He agreed to have an EKG done.  The plan is to continue him on lithium 900 mg at bedtime to help him sleep and relax, and continue to monitor him closely and follow the lithium levels.  He would be followed regularly by Psychology as well as Psychiatry.  I am going to continue to treat him and provide therapy.  I will see him back in my clinic in approximately 4 weeks.



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