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Psychiatric Evaluation Sample Medical Transcription Report

Psychiatric Evaluation Sample Medical Transcription Report

Psychiatric Evaluation Sample Medical Transcription Report

IDENTIFICATION:  This is a (XX)-year-old single male.

PRESENTING COMPLAINT:  The patient reported history of difficult childhood and depression.
HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male who reported significant medical history of surgery on his left hand after he injured it.  He also reported surgical procedures done on both knees for cartilage repair and drainage of fluid as well in the past.  He did not report any other significant history of medical problems.  According to the chart, he had a problem with gastroesophageal reflux, and in the past, at one point, he had elevated liver function tests.  Apart from that, there was no other significant history provided.  The patient stated that he had a very difficult childhood.  He was physically abused by his father from the age of 4 up until he was 15.  He stated that he had received beatings with sticks, belts, and with his hands.  He was emotionally very disturbed.  When he was a child, he attempted multiple times to kill himself.  He stated all these suicide attempts were because of his physical abuse, to get away from his father.  The patient stated that he was diagnosed with hyperactivity and was treated with medication, Thorazine, which actually sedated him too much and made him like a zombie.  He stated that he took the medication for two years but later on stopped it, after two years, because of the significant side effects and no improvement.

He stated that he was tried on other medications, which he does not remember, but all of his medications were stopped at age 12 when they were found to be not helping him at all.  He stated that he was getting into a lot of trouble, which included fighting, anger control problems as well.  The patient stated that he tried to kill his father on multiple occasions but failed.  At one point, he had tried to stab him twice; at another point, he had injured his back to the point that he was admitted to a hospital.  The patient stated that since age 12, when his medication was stopped, he did not pursue any psychiatric treatment up until many years later.  He stated that during this period he endured a lot of stress.  He reported that in (XXXX) his mother died.  He stated that, after the death of his mother, he started having nightmares and flashbacks, which really bothered him and he was not able to rest at all.  He was started on multiple medications.  At one point, he had taken Remeron, but later, he was started on Elavil and valproic acid, which is Depakote.  The patient stated that Elavil was to help him sleep and Depakote actually was more for his migraine headaches, which were excruciating, and since he had been started on Depakote, his migraine headaches had significantly improved.

At the time of assessment, the patient stated that he continued to have flashbacks and had difficulty sleeping.  He stated that Elavil, he is taking 150 mg at bedtime, is not very helpful.  He is having lots of side effects including dry mouth, constipation, and weight gain.  He wanted to stop Elavil and try some other antidepressant.  He also stated that he wanted to continue Depakene but at a lower dose because he was told that his blood level was higher than normal so he wanted to decrease his medications.  The patient stated that he was willing to take some other antidepressant and agreed to have a washout period.  He was very understanding about the risk of changing the medication including some period when he would be without medication and his condition could get worse, but he was willing to take that chance.  At the time of assessment, he reported that he was eating okay.  He continued to complain of some depressed mood.  Denied any suicidal ideation.  He reported significant homicidal ideation against his father and the family.  He did not report any specific homicidal ideations.  These homicidal ideations were conveyed to psychologist, Mr. (XX), and these issues would be brought up in psychiatric review team meeting.  He did not report any other history of auditory or visual hallucinations or any other side effects.  He felt safe.

The patient reported extensive history of alcohol and drug abuse.  He stated that he started drinking alcohol at a very young age.  He would steal from his grandparents, but he started drinking on regular basis at age 15.  His last drink was in (XXXX).  He admitted to having blackouts, shakes, but denied any DUIs or public intoxication charges.  He was 4/4 on CAGE questions.  He also admitted to marijuana use daily, approximately 3 ounces per day, since an early age.  He admitted to have mixed it with cocaine and smoked it, and he also admitted to have snorted cocaine but he stated that it was not regular; it was only on the weekends, whenever he could find.  He stated that his last substance abuse was in (XXXX).

PAST MEDICAL HISTORY:  As discussed above.
PAST PSYCHIATRIC HISTORY:  As discussed above.
PERSONAL HISTORY:  The patient was single and had three children.
ALLERGIES:  NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY:  Significant for some kind of mental illness and alcohol and drug abuse.  He stated that all of his family was “crazy.”  He did not report any history of suicide in the family.
 
MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male sitting on a chair.  He was alert, oriented, and cooperative.  Concentration and memory intact.  Speech was normal rate, flow, and tone.  Language was appropriate and goal directed.  Mood was mildly depressed.  Affect was somewhat sad.  No suicidal ideation.  No active homicidal ideation, although he had homicidal ideation against his father and his family.  No auditory or visual hallucinations or delusions noted.  He seems to have reasonable insight into his situation.  His judgment was intact.
DIAGNOSES:
Axis I:            1.  Posttraumatic stress disorder, chronic.
                        2.  Alcohol dependence.
                        3.  History of polysubstance abuse.
Axis II:            Antisocial personality disorder, borderline personality disorder.
Axis III:           Migraine headaches, gastroesophageal reflux disease.
Axis IV:          Legal problems.
Axis V:           Global Assessment of Functioning is 70-75 at the time of assessment.

TREATMENT PLAN:  The patient was seen.  He was educated about symptoms of mental illness and available resources, risks, benefits, side effects of his medications including present medication, Elavil and Depakote.  He was able to ask questions.  He understood the side effects of dry mouth, constipation, blurring of vision, weight gain, organ effects including effects of Elavil on the heart as well as effects of valproic acid on the liver, pancreas, bone marrow, and blood.  He was able to understand about the risks of hair loss, weight gain, tremors, and other side effects from Depakote.  The patient had stated that his medications were not really helpful with his condition.  He was interested in taking another antidepressant.  He was explained in detail that since he was on Elavil, that he would have to have a washout before another medication could be started.  He was able to understand and ask questions about the risk of changing the medication including worsening of mood disorder, psychosis, risk of suicide.  He wanted to try another antidepressant.  He agreed to undergo a period of washout of 7 to 10 days.  Risks, benefits, and side effects of Celexa including sexual side effects, risk of mania, serotonin syndrome were discussed in detail.  He was interested in trying.  We will start him on Celexa 20 mg after receiving a washout.  His last labs were discussed with him.  The patient agreed to continue Depakote at the present time with a plan that once his Celexa is stable that his Depakote dose would be reduced to minimum dose possible.  His case was discussed in detail with Mr. (XX), who is going to provide him with therapy focusing on the issue of his past trauma, mental illness, and substance abuse.  I will continue to follow him closely and provide medication and therapy.  I will see the patient back in approximately 4 weeks.  We will continue to do regular blood tests as well.

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