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Psychiatric Consultation Medical Transcription Sample



REASON FOR CONSULTATION:  Consultation was requested for evaluation and management of suicidality.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who was admitted subsequent to ongoing difficulties with heavy alcohol consumption. The patient had seizures and loss of consciousness and was transferred to this facility for further cardiac evaluation. The patient states that he is now feeling much better and that the initial problems have been resolved and does not know why he is still in the hospital. The patient has been having difficulties with increased irritable mood and becomes easily upset. He has had difficulties with initiating sleep, stating that at times he will stay up late in the night and also reports that he sleeps most of the day. The patient had reported also maintaining interest in pleasurable activities.  He presents with some issues of low self-esteem, but reports that he maintains hope that things are going to get better now that he is getting medical care.  The patient presents with lowered energy levels. He describes some difficulties with concentration. He reports no major changes with his appetite; although, his wife states that he was eating less and less every day. The patient presents with psychomotor activity, which is within normal limits. He maintains fair eye contact. He denies having homicidal or suicidal thoughts at this time. He reports that he did make a statement to the effect that if his health was not going to get better, then there was no reason to continue to live in this fashion, but he reports no particular plan of wanting to harm himself or anyone else. He denies having auditory or visual hallucinations.

PAST PSYCHIATRIC HISTORY:  The patient has no previous history of inpatient or outpatient psychiatric care. He has been on no psychotropic medications previously.

FAMILY HISTORY:  The patient denies any family history of psychiatric, addictive or neurologic disorders.

PAST MEDICAL HISTORY:  The patient has a history of coronary artery disease. He had seizures secondary to alcohol withdrawal.

SUBSTANCE ABUSE HISTORY:  The wife reports that the patient was drinking on a daily basis from approximately noon until the night. The patient was drinking mostly whiskey. The patient denies any other drug consumption. He reports no previous rehabilitations or detoxifications.

REVIEW OF SYSTEMS:  As per the attending physician.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient reports that he was born and raised in (XX). The patient states he has been married on 3 occasions and worked (XX) years as a (XX). The patient states that he has 4 children and he is currently married. He is living with his wife. All of his children are adults. He is now retired.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who appears older than his stated age. He presents with psychomotor activity, which is decreased. He was dressed in a hospital gown, in bed, is cooperative with the examiner. His speech is of normal tone. It is coherent, relevant, goal directed and logical. His mood is angry. His affect is appropriate to his mood and thought content. He denies having auditory or visual hallucinations and he denies any plans or intent of harm to self or to others. He reports no homicidal or suicidal thoughts. He is alert and oriented to person, place and partially to time. Immediate recall is intact for 3 objects. Recent recall is limited to 2 of 3 objects at 5 minutes. Remote recall is grossly intact. Attention and concentration are limited. Fund of knowledge is adequate for the patient's level of education. Insight is limited. Judgment is fair. Impulse control is fair.

Axis I:  Depressive disorder, not otherwise specified. Alcohol dependence.
Axis II:  Deferred.
Axis III:  Status post alcohol withdrawal with delirium tremens, coronary artery disease.
Axis IV:  Moderate for social and health care issues.
Axis V:  Global Assessment of Functioning of 45.

RECOMMENDATIONS:  The patient at this time does not meet criteria for involuntary hospitalization and states that he has no interest in remaining in the hospital for any type of care that is not essential. The patient could benefit from the use of antidepressant medications but states that he has no interest in taking any medications and will not, if in fact they will not help his overall mood. He states that what is keeping his mood irritable is the mere fact of being in the hospital. The patient at this point should have further outpatient psychiatric followup upon his discharge from the hospital for further assessment of need of psychotropic medications.

Thank you very much for allowing me to participate in the care of your patient.

Mental Status Examples                                 Psychiatric Discharge Summary Sample