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Psychiatric History and Physical Transcription Sample Report

IDENTIFYING INFORMATION:  The patient is a (XX)-year-old Hispanic male who had dropped out of high school and pursuing a GED.

SOURCE:  History obtained from the patient, who had fair to good reliability on review of chart.

CHIEF COMPLAINT:  "I was drunk and did something stupid."

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male without prior psychiatric history but a history of alcohol, cocaine and cannabis abuse, who was brought to the emergency room. The patient was intoxicated on alcohol, cocaine and marijuana when he got into an argument with his father over the cell phone, at which time, he put a wire cord around his neck. The police were called and they brought him into the ER. His UDS in the ER was positive for alcohol at 0.19, cocaine and marijuana. The patient stated he was quite drunk at that time and was not thinking about what he was doing. He had no suicidal ideations and denied it in our interview. In the recent past, he has been doing his normal daily activities. His appetite and sleep have been normal. He has not been depressed. He usually likes to wind down after a day of working out by using alcohol and marijuana. In the ER, he became quite upset when he found out that he would not be able to leave the emergency room, but he was able to calm down by himself.

PAST PSYCHIATRIC HISTORY:  No prior hospitalization or suicide attempts. He identified that he did have anger issues. He has gotten into fights at school in the past but that has been decreasing. He is happy on most days and denied any history of major depression, manic or hypomanic episodes.

PAST SUBSTANCE ABUSE HISTORY:  The patient has been drinking increasing amounts of alcohol. He uses that mainly to relax from a day's work. He denied any withdrawal symptoms when he stops drinking. He uses cocaine very rarely. He uses marijuana almost daily and it is also helping to calm him down. He has not been into any substance treatment program.

PAST MEDICAL HISTORY:  The patient denied any history of head trauma or seizures. He has no medical illnesses.

ALLERGIES:  No known drug allergies.

CURRENT MEDICATIONS:  None.

FAMILY HISTORY:  The patient’s mother was dependent on methamphetamine. He does not know of any other psychiatric illnesses in the family.

SOCIAL HISTORY:  The patient denied any history of physical or sexual abuse. His parents have been separated for a few years. He currently lives with his father and 2 brothers at home. He is the oldest and he tries to serve as a role model. He does not get along with his father and he thinks this is mainly because of his mouth. He used to attend high school but dropped out in the 11th grade and has been pursuing a GED. He does have a girlfriend.

MENTAL STATUS EXAMINATION:
The patient is well-groomed, cooperative. Psychomotor activity is normal. Eye contact good and appropriate. Speech is clear and spontaneous with normal rate, volume and quantity. Mood is euthymic. Affect is happy, full and congruent to mood. In regards to thought content, he denies any auditory or visual hallucinations and did not appear to be responding to internal stimuli. His thought was linear without paranoia, delusions, suicidal or homicidal ideations. In regards to memory, he was alert, oriented to person, place, time and situation. Memory is fair. Attention good. Language grossly intact. Abstraction concrete. Insight is fair. Judgment is fair. Impulse control is good.

REVIEW OF SYSTEMS:  Other than back pain, it was unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 140/82, pulse 50, temperature 98.6 and respirations 18.
GENERAL APPEARANCE:  The patient was not in acute distress, well-nourished male.
HEENT:  Extraocular movements are intact. Pupils are equally round and reactive to light.
NECK:  No abnormal masses.
HEART:  Regular rate and rhythm. No murmurs.
LUNGS:  Clear to auscultation bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN:  Normoactive bowel sounds, nontender, nondistended.
EXTREMITIES:  Full range of motion in all extremities.
NEUROLOGIC:  Cranial nerves II through XII grossly intact. Gait normal.

DIAGNOSTIC STUDIES:  LFTs within normal limits. TSH 2.42 which was within normal limits. CBC was within normal limits. The electrolytes are within normal limits other then a carbon dioxide elevated at 31. UDS was positive for alcohol of 0.19, cocaine and THC.

FORMULATION:  The patient is an (XX)-year-old male with a genetic predisposition for substance dependence. He has already been abusing substances as a way of coping with daily stress. His use of substances may also be affecting his mood and behavior. He appears to have a history of using aggression to get his needs met. He has a non-intact family and has not been able to come to a compromise with his father.

DIAGNOSES:
AXIS I:
1.  Mood disorder, not otherwise specified.
2.  Substance-induced mood disorder, provisional.
3.  Alcohol abuse.
4.  Cannabis abuse.
5.  Rule out cocaine abuse.
AXIS II:  Deferred.
AXIS III:  Back pain.
AXIS IV:  Support, educational.
AXIS V:  Global Assessment of Functioning is 51 to 55.

PLAN:  No medications indicated at this time. Social work to arrange a family meeting to have the patient and parents come to more amicable terms before his discharge. We will recommend substance treatments. Social work to assist with case management, disposition and planning. The patient is likely dischargeable after the family meeting.


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