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Psych Consult Medical Transcription Sample Report


IDENTIFICATION:  The patient is a (XX)-year-old Hispanic female.

SOURCE:  Information obtained from medical records and the patient, who appears to be a fairly reliable source.

CHIEF COMPLAINT:  Medication refill.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with polysubstance abuse and depressive disorder who presents reporting that she would like a medication refill. Psychiatry was asked to evaluate for some bizarre behaviors. The patient with self-reported depression, also involved in some self-injurious behavior, which involves the patient picking at her skin. On interview, the patient reports that she has been dealing with both emotional and physical pain. In terms of her physical pain she explains there is some back pain. Emotionally, she has been involved in a relationship and reports that for the past couple of days, that male has not wanted to speak with her and that is the source of stress for her. On interview, the patient appears linear, denies any suicidality, does appear to have some cognitive impairment. The patient with decreased insight into her history.

PAST PSYCHIATRIC HISTORY:  The patient again has history of polysubstance dependence, including benzodiazepines and opioids.

SUBSTANCE USE HISTORY:  No current use of substances. In the past, she has used opioids and benzodiazepines.  The patient has a history of alcohol abuse. No noted tremors or seizures or other withdrawal symptoms. The patient has abstained from alcohol for the past 10 years. The patient smokes one to two packs per day.

PAST MEDICAL HISTORY:  Includes history of irritable bowel syndrome, fibromyalgia, and myocardial infarction.

CURRENT MEDICATIONS:  The patient is unable to recall most recent medications.

1.  Paxil.
2.  Amitriptyline.
3.  Wellbutrin.
4.  Trazodone.
5.  Soma.
6.  Lexapro.
7.  Effexor.


SOCIAL HISTORY:  The patient is unmarried, lives on her own. Collects social security benefits.

MENTAL STATUS EXAMINATION:  The patient appears disheveled in appearance, appears older than stated age. She makes good eye contact. Her speech is of normal rate, tone, and prosody. She displays no psychomotor agitation or slowing. Her mood appears euthymic, but her affect is constricted. The patient is at times tangential in terms of her thought process. Thought content:  She denies any suicidal or homicidal ideations. No delusions detected. She denies any auditory or visual hallucinations or history of hallucinations. Her judgment and insight appear fair.

DIAGNOSTIC DATA:  Sodium 136, potassium 3.4, chloride 101, CO2 of 30, calcium 8.6. Glucose 96. Liver function tests within normal limits with the exception of a decreased albumin at 2.7. CBC showing slightly elevated white count at 12.9. The rest of the CBC and differential within normal limits.

IMPRESSION:  The patient is a (XX)-year-old female with a history of depression.  Judging from the patient's current presentation, biological factors include history of chronic medical illness and the patient also has history of substance use and is status post remission for over a decade. Psychologically, the patient seems to be intact with intact coping mechanism as the patient has been able to not require inpatient hospitalization for quite some time.  The patient is living on own, appears to have good resources. In terms of her decreased memory, there is a question of whether there is a component of dementia in her presentation. Socially, the patient appears to be linked with case management services and appears to have somewhat supportive social environment though there are some acute stressors present. The patient is able to live on her own.

AXIS I:  History of major depressive disorder. Rule out dementia.
AXIS II:  Diagnosis deferred.
AXIS III:  History of irritable bowel syndrome, fibromyalgia, and polysubstance abuse.
AXIS IV:  Problems with social environment and occupational functioning.
AXIS V:  50.

PLAN:  The patient does not require inpatient admission at this time in terms of acute stabilization. The patient appears to have no suicidal symptoms or acute symptomatology. The patient will be discharged home and will follow up with the psychiatrist.

Mental Status Examples                                Psychiatric Discharge Summary Sample