REQUESTING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Psychiatry consultation to assess for decisional capacity.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with no known past psychiatric history admitted for multiple medical problems. Psychiatry was called to assess for decisional capacity. The patient did not have the capacity to make healthcare decisions and the patient’s brother had signed as the surrogate decision-maker. Upon interview, the patient was found to be not oriented to place, was not able to give his full name unless it was stated, and he was able to recognize his name. The patient also was only able to name the year, otherwise was not oriented to situation.

The patient denied that he knew his reason for hospitalization, denied knowing that he had a complicated course of hospitalization that required ICU admissions, and could not provide any other information in regards to his medical care. Therefore, the patient is not able to communicate his needs. There is no consistent communication of his decision. He is not able to provide any of the risks and benefits of treatment versus no treatment, and he is unable to process the information provided to him.

PAST PSYCHIATRIC HISTORY: Unknown.

FAMILY HISTORY: As regards psychiatric illness is also unknown.

SOCIAL HISTORY: Per medical chart, the patient is estranged from his family and has a brother, who signed as a surrogate decision-maker, according to the medical record. Other social history is unknown at this time.

PAST MEDICAL AND SURGICAL HISTORY: Includes COPD, seizure disorder, opioid dependence due to chronic back pain, lumbar spinal degenerative changes status post multiple surgeries, history of upper GI bleed, history of ileus, hyperlipidemia, cardiomyopathy, diabetes, acute renal failure requiring hemodialysis, right arm cellulitis, Klebsiella pneumoniae, history of respiratory failure, as well as myocardial infarction.

MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic male with notable labored breathing, drowsy, but responsive to verbal stimuli, with intermittent eye contact. No psychomotor agitation or retardation noted. Speech is very labored secondary to his mild respiratory distress, whispering when speaking and very difficult to understand. Mood is okay. Affect is euthymic. Thought content is unable to be assessed secondary to the patient’s mild respiratory distress. Otherwise, he did not verbalize any thoughts of self-injury or harm to others and was not noted to be responding to internal stimuli during interview. Thought process demonstrated poverty of thought. Insight and judgment was determined to be poor to limited.

DIAGNOSTIC IMPRESSION:
Axis I: Delirium.
Axis II: Deferred.
Axis III: Multiple medical conditions, as noted above.
Axis IV: Problems with social support, multiple medical conditions.
Axis V: Global Assessment of Functioning of 0 to 5.

IMPRESSION: This (XX)-year-old male with no known past psychiatric history was admitted for multiple medical problems. The patient at this time does not have the decisional capacity for healthcare decisions. According to the medical chart, the patient was found to have decisional incapacity with a surrogate decision-maker as his brother. Again, the patient was unable to communicate his needs to make a consistent choice and unable to provide the risks and benefits of treatment nor to process the information.

RECOMMENDATIONS: Social work aid to determine proper surrogate decision-maker. If the patient’s brother is uncomfortable with being the surrogate decision-maker, may want to consider getting public guardianship. Otherwise, recommend that medical team work with the patient’s brother in regards to healthcare decisions. Case and plan discussed with and agreed by attending physician.

The post Psychiatry Consultation Transcribed Sample Report appeared first on Medical Transcription Sample Reports.

SOURCE OF INFORMATION:  Self and previous records.

PRESENTING PROBLEMS:  The patient was hospitalized at (XX) Center from MM/DD/YYYY to MM/DD/YYYY for worsening depression. She was discharged on the same medications that she was hospitalized on, namely trazodone 150 mg at bedtime and clonazepam 0.5 mg t.i.d. These are the medications started by her primary care physician a few weeks ago. The patient complains of multiple symptoms of depression. She is having frequent mood swings, sometimes several swings in one day. She thinks that overall her depression is somewhat better considering that it is summer. In winter, she states she really gets worse. She is sleeping well with the help of trazodone, while her appetite is also getting better. Prior to hospitalization, she had lost 15 pounds. She often feels tired. She cries every day. She does not feel hopeless or helpless. Her concentration is poor. She has poor memory as a result. She has difficulty making decisions. Her self-esteem is poor. She is uncomfortable around people.

The patient admits to having symptoms suggestive of mania. There have been times, lasting for up to one week, when she has been a bundle of energy with decreased need for sleep. She had racing thoughts. She would become creative and want to start multiple projects at once. She would make rash decisions. She would want to spend excessively. The patient states that probably her continued symptoms of depression are related to severe stress with her three daughters and their continued troubles with the law. The patient thinks one of her daughters has bipolar disorder. They are constantly fighting with each other, which exacerbates her stress levels. She also does not get along well with her daughters because of the above reasons, and because of the ongoing conflict with her daughters, she ended up missing quite a few days at work and eventually lost her job. The patient denies any symptoms suggestive of hypothyroidism or hyperthyroidism. She denies any symptoms of psychosis. She denies taking steroids or beta blockers.

PAST PSYCHIATRIC HISTORY:  The patient has an extensive psychiatric history. Her first hospitalization was (XX)years ago because she attempted suicide. She had another hospitalization in (XXXX). In the past four years, she has had four to five other inpatient treatments. She followed up with Dr. John Doe for four years. She also followed up with Dr. Jane Doe for two months. Over a period of time, she has been tried on multiple antidepressants. She was also briefly tried on lithium. She discontinued the medication on her own after one month.

SUBSTANCE ABUSE HISTORY:  The patient has not used drugs on a regular basis for more than 15 years. She does admit to using marijuana one month ago, which was again after several years of being clean, per her. She has used cocaine in the past continuously for eight months before stopping. She has never used IV drugs.

MEDICAL HISTORY:  The patient is a borderline diabetic and is maintained on diet. She had complete hysterectomy because of endometriosis.

SOCIAL HISTORY:  She describes having symptoms of ADHD as a child. She graduated from school. While currently she is unemployed, she was employed until recently. She has been married two times, each marriage lasting for a short period of time. She has three daughters from the two marriages. Currently, she is staying with her first ex-husband because reportedly she and her daughter were thrown out of her boyfriend’s place.

MENTAL STATUS EXAMINATION:  The patient is appropriately dressed and groomed. She is cooperative and communicative. She maintains eye contact. Rapport is limited. Psychomotor activity is normal. No involuntary movement. Speech is spontaneous with normal volume and tone. She describes her mood as depressed. Her affect conveys depression. She denies any suicidal or homicidal ideations or abnormal perception or delusions. Her judgment is intact. She has insight into her illness.

DIAGNOSES:
AXIS I:
1.  Bipolar disorder, mixed type.
2.  Rule out major depressive disorder, moderate and recurrent.
AXIS II:  Rule out borderline personality disorder.
AXIS III:  Status post total hysterectomy and borderline diabetes mellitus.
AXIS IV:  Severe stress in the form of multiple failed relationships and ongoing conflict with three daughters.
AXIS V:  50.

RECOMMENDATIONS:
1.  The patient does not pose any imminent danger of harming herself or others; therefore, she should continue to attend the program.
2.  The patient does not report any major side effects associated with Klonopin and trazodone; therefore, both should be continued at the current dose. She should be started on Depakote 250 mg at bedtime for one week and 500 mg at bedtime for one week and then 750 mg at bedtime. At that point, Depakote level will be advised. Efficacy and side effect profile of this medication was reviewed with the patient. She was also provided with information brochure on bipolar disorder and Depakote.
3.  The patient will be evaluated at weekly intervals while in the program.

The post Psychiatric Sample Evaluation Medical Sample Report appeared first on Medical Transcription Sample Reports.

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation of agitation and paranoid behavior.

IDENTIFICATION:  The patient is a (XX)-year-old African-American female who was admitted to this facility via the emergency department.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female who was admitted to this facility via the emergency department. The patient is a resident of a skilled nursing home facility. The patient was presenting with an episode of questionable chest pain. She has a history of frequent urinary tract infections, history of asthma, and previous history, several years ago, of hepatitis. The patient has had a history of progressive cognitive decline. The patient has been a resident of the nursing home for a few years now. The patient is reported to have periods of increased suspiciousness and paranoid behavior. It was reported that the patient often was very reluctant in taking medication and sometimes the level of paranoia interferes with her care, where she is refusing care, does not want to eat, feels that food has been poisoned, and can be very oppositional with staff.

The patient has not received any recent psychiatric treatment for this behavior, but she has a previous history of depressive disorder. She did receive antidepressant medication, Prozac. Also, she has a previous history of excessive symptoms of anxiety, for which she received Xanax and Ativan. The patient has a history that dates back to several decades ago when she sustained a head injury, and there were changes in her behavior. The patient was unable to return back to work after this incident. At that point, the patient was having some behavioral changes. Most recently, the patient has had a decline in cognition, problems with short-term memory, attention, concentration, and reasoning.

There is no history of alcohol abuse or abuse of prescription medication. She does not smoke cigarettes. She has been living in the nursing home in recent years. The patient always had multiple complaints about her care, even when the care was appropriate. At this time, she is asking to return home, but the family described the patient is unable to care for herself and that it is not feasible since the level of the support is not there for her to return after having multiple complaints of the current facility where she resides.

PAST PSYCHIATRIC HISTORY:  Previous history of psychiatric treatment. No history of inpatient treatment. No history of suicidal attempt.

FAMILY PSYCHIATRIC HISTORY:  Negative.

MEDICAL HISTORY:  See history of present illness.

PHYSICAL EXAMINATION:  Blood pressure 112/68, respirations 18, pulse 80, and temperature 97.4.

REVIEW OF SYSTEMS:  The patient is unable to provide reliable information regarding 14-point review of systems.

SUBSTANCE ABUSE HISTORY:  No history of alcohol abuse or abuse of prescription medication.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old female who was lying in bed. The patient has difficulty hearing. Very suspicious with periods of agitation. Thought process was illogic, thoughts tangential. Is paranoid and clearly responding to internal stimuli. No suicidal or homicidal thoughts. She is alert and oriented only to person. Impaired attention and concentration. Impaired insight and judgment. Poor recall. No awareness of current events. Unable to name objects or repeat phrases.

DIAGNOSTIC IMPRESSION:
Axis I:
1.  Superimposed delirium disorder.
2.  Dementia disorder with behavioral disorder.
3.  Psychotic disorder, not otherwise specified.
4.  Cognitive disorder secondary to head injury.
5.  History of depressive disorder.
Axis II:  Deferred.
Axis III:  See medical section.
Axis IV:  Current health problems.
Axis V:  Global Assessment of Functioning of 40 to 45.

SUMMARY AND RECOMMENDATIONS:  The patient is a (XX)-year-old female who was admitted to this facility. Psychiatric consultation was requested to evaluate the patient who has presented with periods of agitation and restless-type behavior. At this time, we discussed with family initiation of a trial of Haldol 0.5 mg IV q.12 h. x 48 hours and also consideration in the future of a small dose of Risperdal 0.25 mg at bedtime. Continue to provide the patient with frequent orientation.

Thank you for allowing me to participate in the care of this patient.

The post Agitation Paranoia Consult Medical Transcription Sample Report appeared first on Medical Transcription Sample Reports.