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Medical Transcription Psychiatric (Psych) Consultation Transcribed Sample Report




REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female with a history of end-stage COPD, previous CVA, seizure disorder, chronic headaches and chronic pain syndrome, who was admitted to the hospital yesterday for increasing pain all over the body.  She has also expressed feelings of severe depression, and a psychiatric consultation was requested for evaluation of the same.  The patient reports that she had been going through a lot for the past few months.  She was referring to her medical problems, chronic obstructive pulmonary disease, especially the pain all over the body for which no clear organic reason has been found so far.  She says that she is hurting all the time, constantly.  She is tired of it.  She cannot take care of herself, and she was recently in the nursing home but had a bad experience over there, and she does not want to go back to the nursing home.  She was living with a man for 15 years, but he is not able to take care of her.  She was very helpless and hopeless, and she voices passive death wishes but denies any active intentions.  She says that she will never do that to her and her friend.  She does admit to having insomnia and extremely depressed crying episodes and reports very poor energy level, motivation, loss of interest and feeling sad and unhappy all the time.  She had some depression symptoms in the past, related to the medical problems, and was placed on Lexapro and Seroquel for sleep for the past few weeks, but it is not helping.  Seroquel helped for her sleep, but she does not want this medication as she knows this is an antipsychotic.  She denies any delusions or hallucinations.

PAST PSYCHIATRIC HISTORY:  No history of any psychiatric illness or psychiatric hospitalization or any suicidal attempts in the past.

PAST MEDICAL HISTORY:  As stated above.

CURRENT MEDICATIONS:  On admission, Protonix, Synthroid, Nitro-Dur patches, Tenormin 25 mg once a day, Ditropan, Atrovent, Nasonex, multivitamins, Os-Cal, Bumex, Imdur, Micro-K, Lexapro 10 mg daily, magnesium oxide, Klonopin 0.25 mg every 12 hours, Seroquel 100 mg nightly, Phenergan p.r.n., and Pulmicort inhaler.


PSYCHIATRIC MENTAL STATUS EXAMINATION:  The patient is a thinly built female who appears to be in moderate distress from pain.  She is generally cooperative, pleasant, shows significant psychomotor retardation but no agitation.  She speaks in a very low volume voice.  She is alert and oriented in all three spheres.  Memory grossly intact in all modalities.  Speech is coherent.  Mood is depressed, tearful, constricted affect.  No evidence of any overt psychosis or hypomania.  She does have passive death wishes, however, denies any active suicidal intentions or thoughts.  Insight and judgment questionable.  Intellectual abilities in average normal range.

Axis I:  Major depression, single episode, moderate to severe with anxiety component.
Axis II:  Deferred.
Axis III:  Chronic pain syndrome, narcotic dependence, chronic obstructive pulmonary disease, status post cerebrovascular accident, and seizure disorder.

RECOMMENDATIONS:  The patient does not appear to be responding to her current psychotropic medications, so I will discontinue the Lexapro and Seroquel.  Instead, we will use Effexor XR 37.5 mg once a.m. and also Desyrel 50 mg nightly.  We will continue to monitor the patient closely.