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Psychiatry - Transcribed Medical Transcription Sample Report / Example

IDENTIFYING DATA:  The patient is a (XX)-year-old male.

CHIEF COMPLAINT:
1.  Bipolar affective disorder.
2.  Obsessive-compulsive disorder.
3.  Anxiety and depression.

HISTORY OF PRESENT ILLNESS:  According to the patient, he suffers from severe mood swings that alternate between depression and mania.  During depressive episode, he experiences depressed mood most of the day, nearly every day on irregular and persistent basis.  He experiences markedly diminished interest and pleasure in almost all pleasurable activities.  His appetite becomes very poor, and there have been times when he has lost more than 5% of his body weight.  He has difficulty sleeping.  He tosses sometimes all night.  He also experiences psychomotor agitation and becomes very irritable and unable to tolerate frustration.  He isolates himself and becomes easily fatigued, associated with loss of energy.  He also admitted to feelings of worthlessness and hopelessness with diminished attention and concentration.  He has recurring thoughts of death and recurrent suicidal ideation without a specific plan.  He also admitted to having episodes of bipolar illness that is characterized by manic episode.  During the manic episode, he experiences inflated self-esteem and ideation of grandiosity with decreased need for sleep.  He becomes more talkative than usual and has a pressure to keep talking.  He also experiences flight of ideas and has subjective experience that thoughts go racing very fast in his head.  He becomes easily distractible and unable to focus on any particular task.  He will engage in multiple tasks without completing any of the tasks.  He also experiences obsessive-compulsive symptoms.  He experiences recurrent and persistent thoughts, impulsive and immediate, that are experienced on a regular basis; most of the thoughts fixing on any particular item.

Any attempt from him to ignore or suppress the thoughts brings about considerable anxiety.  He was treated with Zoloft, Zyprexa, and Xanax.  He also admitted feeling very paranoid, suspicious, and guarded.  Of late, he was put on Celexa 20 mg in the morning and Seroquel 100 mg at night.  According to him, he continued to experience the symptoms of anxiety and depression.

PAST PSYCHIATRIC HISTORY:  He was admitted as an inpatient in the past.  He denied any past history of suicide attempt.

ALLERGIES:  None.

MEDICAL HISTORY:  He denied any head injury or seizures.

DRUG AND ALCOHOL HISTORY:  He admitted to abusing alcohol on a sporadic basis, and he experimented with heroin in the past.  However, it appeared he was not telling the whole truth about the extent of his drug and alcohol abuse.

FAMILY HISTORY:  He has a sister who is autistic and also suffers from ADHD and OCD.

PERSONAL AND DEVELOPMENTAL HISTORY:  The patient was born and raised in (XX).  He has (XX)th grade education. 

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old Caucasian male who is fairly well groomed and appeared his stated age.  During the interview, marked psychomotor restlessness was observed.  He has difficulty maintaining adequate eye contact.  His speech has no coherence, spontaneous.  However, he was able to express himself verbally.  He described his mood as anxious.  Objectively, his mood is severely dysphoric.  His affect is restricted, despondent, and extremely agitated.  He has difficulty expressing spontaneous emotional reactivity.  His behavior is appropriate.  His memory is very poor for recent events.  He was however awake, oriented to time, place, and person.  His concentration and attention were both impaired.  He has difficulty doing serial 7s and he was unable to add or subtract figures without difficulty.  General level of intelligence and fund of general knowledge appears to be within normal limits.  His level of personal hygiene is fairly good.  He has difficulty communicating, clearly due to his anxiety level.  However, he was able to achieve goal directed ideas.  He denied any suicidal or homicidal ideation.  His level of abstract reasoning is fairly intact.  It was very difficult to maintain any form of rapport with the patient throughout the interview, and he has difficulty following directions.  He has present ideation of worthlessness and hopelessness.  He, however, denied any auditory or visual hallucination.  He was very much preoccupied about his symptoms.  He has very poor insight into the nature of his marijuana and alcohol abuse.

DIAGNOSTIC ASSESSMENT:

Axis I:            1.  Bipolar affective disorder type 1 with psychotic features.
2.  Obsessive-compulsive disorder.
3.  Mood disorder, not otherwise specified.
4.  Alcohol and marijuana abuse, currently in remission in a controlled environment.

Axis II:            Rule out antisocial and borderline personality disorder.

Axis III:           Denied.

Axis IV:          Psychosocial stressors.

Axis V:           Current Global Assessment of Functioning of 55-60.  Functioning with mild to moderate impairment in activities of daily living and in interpersonal relationships.

PLAN AND RECOMMENDATIONS:
1.  I discussed with the patient the entire spectrum of his symptomatology, the diagnosis, and the need for medication to be adjusted.  I also explained the risks and benefits of the proposed medications to the patient, which were fully comprehended by him.
2.  I started him on the following medications:
a.  Chlorpromazine 100 mg in the morning, 200 mg at night, to target his paranoia as well as irritability.
b.  Valproic acid 0.5 grams p.o. b.i.d. to control his mood swings.
c.  Celexa 40 mg in the morning for his anxiety and depressive illness.
3.  I ordered for complete metabolic profile and VPA level to monitor the level of the drug in his system.
4.  He will also undergo extensive psychological testing to map out his personality profile and overall psychopathology.