Psychological Consultation Medical Transcription Sample Report


DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Dr. Jane Doe ordered a psychological consultation of this patient, who is currently in the emergency department.

IDENTIFICATION:  A (XX) -year-old black male. 

CONTACT PERSON:  Barbara Doe.  She identified herself as a friend.  There is a Release of Information form that was signed.  I do not know how long she has known the patient; however, she identified herself as a friend of the family.

HISTORY OF PRESENT ILLNESS AND REASON FOR ADMISSION:  The patient had indicated that he took 6 Percocet last night.  His record had an admission for a number of different dates, including MM/DD/YYYY, MM/DD/YYYY and MM/DD/YYYY.  In any case, this patient had been admitted to psychiatric facilities with a diagnosis of bipolar affective disorder or manic depressive illness, not otherwise specified, in the past.  The patient is reportedly on a variety of psychiatric medications, including Depakote.

PATIENT STATEMENT:  This patient made threatening statements of harm to an individual, who assaulted him recently.

CONTACT STATEMENT:  The patient's friend, Barbara, reported that the patient has been hallucinating and has been getting progressively worse.  She also reported that he took 16 Percocet, and not 6, as he said.

EMERGENCY DEPARTMENT CHIEF COMPLAINT:  The chief complaint was an overdose.

RECENT STRESSORS:  The patient indicated he had been assaulted by his brother-in-law.

PAST PSYCHIATRIC HISTORY:  Inpatient:  The patient reports a history of multiple psychiatric hospitalizations.  He indicated at least 6 of them.  Outpatient:  The patient did not indicate a history of outpatient treatment.  I am unable to determine how well he followed up on any outpatient basis.

SOCIAL SECURITY DISABILITY INCOME (SSDI):  It is not known whether this patient is on SSDI.  He did at one point suggest that he was not on SSDI, however.

HISTORY OF SELF-HARM BEHAVIOR:  There is a history of self-harm behavior.  The patient stated that he had had suicidal thoughts, and he said the last time was 1 year ago; however, he did take a recent overdose.

HISTORY OF VIOLENT BEHAVIOR:  Unknown.  However, the friend reported that there is a history of some kind of violence on this patient's part.

FAMILY PSYCHIATRIC HISTORY:  The family psychiatric history is unknown.

MEDICAL HISTORY:  The medical history of this patient is unknown, other than he has various bruises on his body.

ALLERGIES:  Allergies are unknown as this patient did not respond to questions concerning that.

SUBSTANCE ABUSE HISTORY:  The patient did not respond to questions regarding substance abuse.  It should be noted that this patient is a very poor historian and was very confused at the time of the examination.

SOCIAL HISTORY:  The patient reported he was born in XXXX.  The patient reported he was raised by his parents and his grandfather.  Regarding siblings, the patient states that he has 2 sisters.  He did also make reference to something like 6, but was not clear.

EDUCATION:  The patient reports he has 2 years of college.

CURRENT WORK:  The patient indicates he is retired.

PRIOR OCCUPATIONS:  Prior occupations are unknown.

CURRENT AND PAST LEGAL HISTORY:  The patient has possible arrests for violence in his past.

MARRIAGES:  The patient reported he was married 2 times and is presently divorced.

CHILDREN:  The patient states he has 3 children.

CURRENT LIVING SITUATION:  The patient reportedly lives alone in a hotel. 

WEAPONS OR MEDICATIONS FOR OVERDOSE AVAILABLE:  This is unknown. 

LOCAL SOCIAL SUPPORTS:  The only local social support identified was a friend of the family, who is Barbara, the contact person.

MENTAL STATUS:  This patient took a recent overdose of Percocet.  The patient has threatened harm to his brother-in-law and, additionally, had taken 16 Percocet, but only acknowledged having taken 6.  The patient showed grossly normal development and physique.  Grooming and personal hygiene were poor.  The patient showed pressured speech and depression.  The patient's thought process was somewhat tangential.  The patient expressed that he is having auditory hallucinations and he did express paranoid delusions.  The patient had severely impaired judgment and poor insight.  The patient showed impaired attention and concentration.  His thought process was disorganized.  His fund of knowledge and orientation were quite poor.  The patient's affect was labile.  The patient was alert and agitated.  The patient was pessimistic in his attitude and his mood was irritable.  Regarding dangerousness, the patient had expressed homicidal ideation and ideation of harm to others, and he had indicated self-harm behavior.  The patient showed impaired coordination and some psychomotor agitation.

DIAGNOSTIC IMPRESSION:

Axis I:  296.64, bipolar I disorder, most recent episode mixed, with psychotic features.
Axis II:  Deferred.
Axis III:  Bruises to various regions of body, other unknown.
Axis IV:  Recent assault.
Axis V:  Global assessment of functioning:  Current = 15.

RECOMMENDATIONS:  This patient should remain admitted, as he is psychotic and is a danger to himself and others.  Following inpatient psychiatric stabilization, he will need outpatient psychiatric followup.


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