Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Psychiatric (Psych) Consultation Medical Transcription Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

REASON FOR ADMISSION:  Altered mental status.

ADMITTING DIAGNOSES:
1.  Polysubstance ingestion.
2.  Suicide attempt.
3.  History of previous suicide attempts.
4.  History of schizoaffective disorder and borderline personality disorder.
5.  Hypertension.
6.  Gastroesophageal reflux disease.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male who was brought to the emergency room today and evaluated.  He admitted to taking various pills in his “pill case."  This apparently included valproic acid, Dilantin, Klonopin, Toprol, Risperdal and Zoloft.  He stated at that time that he had a lot on his mind and he wanted to kill himself.  He had not told anyone about it.  He had not left a note, he had not notified anybody, and he was found by unknown persons who called 911.  He was brought to the emergency room and evaluated formally here.  He has now been transferred into medical intensive care unit for close observation.  The patient does have a longstanding psych history of schizoaffective disorder, multiple admissions for similar ingestions or serious suicide attempts and psychiatric hospitalization.  He also has a history of learning disability, seizure disorder, and substance abuse.  At this time, the patient is not giving a clear story.  He is at times poorly responsive, evasive or giving conflicting stories as to what has happened.  He does deny pain, headache, nausea, vomiting, fever, chills.  No chest pain or shortness of breath.  He looks in no distress.  He is lying in bed comfortably, quiet and he has had stable vital signs since his arrival to the intensive care unit.

PAST MEDICAL HISTORY:  Seizure disorder, learning disability, asthma, GERD, hypertension, and depression.  He has had multiple hospitalizations for psychiatric instability.

FAMILY HISTORY:  Notable for schizophrenia, bipolar disorder, and depression.

SOCIAL HISTORY:  Smokes occasionally.  He denies being a habitual drug user. 

MEDICATIONS:  Prior to admission are Zoloft 50 mg daily, Dilantin 100 mg t.i.d., Depakote 50 mg b.i.d., Klonopin 0.5 mg b.i.d., Toprol-XL 50 mg daily and Risperdal 2 mg at night.

ALLERGIES:  PENICILLIN.

REVIEW OF SYSTEMS:  All negative, though the patient was not fully cooperative.

PHYSICAL EXAMINATION:
GENERAL:  He is lying in bed, afebrile since admission.
VITAL SIGNS:  Blood pressure 118/72, pulse is regular sinus rhythm on monitor at between 60 and 70.  He is 96% saturated on room air.
HEENT:  Head is normocephalic, atraumatic.  Pupils are reactive.  Sclerae are anicteric.  Nares patent.  Oropharynx is benign.  Tongue is midline.
LUNGS:  Clear bilaterally.
HEART:  S1, S2, regular.
ABDOMEN:  Soft.  Bowel sounds active.
EXTREMITIES:  Able to move all extremities.  Full range of motion.  No cyanosis, clubbing or edema.
Speech is clear but tangential or evasive.  He is not fully cooperative with orders.

ADMITTING LABORATORY DATA:  Laboratory assessment shows normal electrolytes.  BUN 17, creatinine 0.6.  GFR 172.  Normal liver function tests, protein, albumin.  Toxicology shows positive benzodiazepines, valproic elevated at 124, phenytoin 9.4.  Coagulation normal.  Hemoglobin of 14.4, white count of 12.2, and platelets 214,000.

ASSESSMENT/MEDICAL DECISION MAKING:  This is a gentleman with known borderline disorder, schizoaffective, who has had multiple hospitalizations for psychiatric reasons, including polysubstance overdose, suicide attempt and other manifestations of lethality directed against himself.  He has also had cases where he has been abusive to staff here and has had issues where he has had issues with others in his family.  His current state is calm and he has already been seen by Psychiatry, who have recommended him to be transferred eventually to inpatient unit.  Pending that, he is in my view hemodynamically stable at this time without showing any fluctuations in levels of bradycardia or hypotension.  He is asymptomatic in terms of the serious consequences of his suspected overdose and would be safe to be going to the floor with one-to-one observation while on a telemetry bed, to be monitored pending his eventual transfer to the psych unit inpatient for psychiatric stabilization.
1.         For his seizure disorder, I will continue his Dilantin, as it seems his level is barely therapeutic, while per psych recommendation, we will hold his Zoloft, Risperdal and Klonopin.
2.         For his hypertension, he is not manifesting that now, so we will hold his Toprol with an eye towards continuing that if he does show hypertension.

He is in need of one-to-one observation and restraints, if needed, to control his behavior.  He is certainly not able to sign out against medical advice since he lacks judgment or insight.  I suspect he may not have had even a serious overdose here, as he is not showing really any physiologic signs of it and this may well be to get attention and another hospitalization.  Nonetheless, these are psychiatric issues that I will defer to their management skills.  The patient is currently stable enough to be transferred out of the intensive care unit.  He was admitted here for close observation because of suspicion for hemodynamic instability, that has not manifested itself in his 6 hours here so far.

Thank you very much for allowing me to participate in his care.  We have monitored the patient in the critical care unit and I have spent time going over the reports, which has amounted to a total of more than 30 minutes of critical care time.



Medical Transcription Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites