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Psychiatric Consult Medical Transcription Sample Report / Example



HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of AIDS who was admitted for treatment of aplastic anemia, pancreatitis, CMV retinitis, and CMV colitis. Consultation was requested for assessment of behavioral issues and the possibility of AIDS dementia. On interview, the patient reported feeling depressed. The patient denied having any suicide plans or intention. He is aware of the severity of his illness and he is not interested in treatment for depression. He does appear to have decisional capacity at this time. Collateral information was obtained from Dr. Doe, and according to him, this is the patient's baseline behavior. The patient was unwilling to participate with cognitive testing to help with assessment for AIDS dementia and he was unwilling to complete the psychiatric interview. He did admit to feeling somewhat depressed. He cited psychosocial stressors, poor finances, and difficulties with his family recently. Further questioning regarding symptoms of depression was unable to be performed due to the patient being unwilling to complete the interview. The patient did deny any homicidal ideations and did not report any auditory or visual hallucinations. The patient does not have much hope for any kind of meaningful recovery.

CURRENT MEDICATIONS:  Acetaminophen, fentanyl citrate, Zithromax, bisacodyl, danazol, Truvada, fentanyl patch, fentanyl PCA, folic acid, foscarnet, Lidoderm patch, lopinavir/ritonavir, normal saline at 100 mL per hour, Zofran, oxycodone immediate release tablet, OxyContin, Neutra-Phos, Klor-Con, Phenergan.

PAST PSYCHIATRIC HISTORY:  The patient denies any history of psychiatric illnesses or having seen a psychiatrist in the past. He does admit that he had tried to commit suicide multiple times.

PAST MEDICAL HISTORY:  AIDS, questionable leukemia, history of CMV colitis with GI bleeding, gastritis, pancytopenia, cardiomyopathy with ejection fraction of 50%, peripheral neuropathy, right eye blindness, AIDS. The patient has been poorly adherent with his AIDS medications.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Unable to obtain psychiatric family history.

SOCIAL HISTORY:  The patient reports that he was living with his father, unemployed.

SUBSTANCE ABUSE HISTORY:  The patient denied alcohol use but does smoke 2 packs per day of cigarettes. He denied any recent illegal drug use; however, he has a history of drug abuse in the past.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male who appears his stated age. He appears somewhat thin but is in no acute distress, although he does appear to be in pain at times. He is lying in bed on his side throughout most of the interview. He is somewhat uncooperative with the interview. The patient displayed poor grooming. The patient made poor eye contact throughout the interview. The patient spoke with somewhat irritable tone, but he spoke in a normal rate and volume. The patient was not describing any tremors or tics. He did not have any psychomotor agitation or retardation. The patient did report feeling depressed. The patient appeared dysphoric and irritable. His affect was constricted and mood congruent and it was appropriate. Thought process linear and concrete. The patient is not expressing any paranoia or delusions. He denies any active suicidal or homicidal ideations but does seem to have passive death wish. The patient did not voice any auditory or visual hallucinations. The patient would not cooperate with testing of orientation, concentration, knowledge, or memory. The patient seems to have a fair amount of insight into his illness and its severity. The patient was expressing somewhat poor judgment at this time.

LABORATORY AND DIAGNOSTIC DATA:  Hematology panel significant for low white blood count and anemia with nucleated RBCs and a low platelet count of 34,000. HIV testing showed HIV-1 RNA by PCR copies of 98,400 and HIV-1 RNA by PCR log copies of 5. CMV DNA quantitative was less than 200. UA significant for trace protein and trace blood. CT scan of the abdomen was normal.

FORMULATION:  This is a (XX)-year-old male with AIDS with multiple infections and complications, who was admitted for treatment of his medical condition. He was assessed by his primary team to be having behavioral issues and there was question of possibility of AIDS dementia; therefore, psychiatric consult was obtained. With further history gathering and collateral from Dr. Doe, it was determined that the behavioral issues are consistent with the patient's baseline behavior. He would not allow for cognitive testing; therefore, possibility of AIDS dementia could not be ruled out completely. At this time, he likely does meet criteria for depression secondary to general medical condition and nicotine dependence; however, he is refusing treatment for either. The patient does appear to have decisional capacity at this time.

AXIS I:  Mood disorder secondary to general medical condition and nicotine dependence.
AXIS II:  Deferred.
AXIS III:  Acquired immune deficiency syndrome.
AXIS IV:  Problems with housing, finances, social and family support, and occupation.  Problems with chronic medical illness.
AXIS V:  Global assessment of functioning 45.

1.  We would suggest ordering an MRI to evaluate for any brain pathology or changes that might be consistent with AIDS dementia.
2.  We would recommend involving Social Work to help with coordinating the patient's social service benefits and to assist with discharge planning, if the patient is having problems with housing.
3.  We informed the patient that if he changes his mind and would be interested in treatment for his depression and nicotine dependence, that we are happy to provide treatment.

Thank you, Dr. Doe, for this interesting consultation.