Sample Transcribed Reports:

Edited Sample Report

This patient is a **-year-old Caucasian married female, who has been feeling depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do much. She feels miserable in the morning and gets a bit better as the day progresses. She is feeling guilty most of the time. She is afraid to be by herself. She his constantly worried of hurting herself.

This patient did attempt suicide 1½ years ago. Following this, she was treated as an in-patient for a brief period of time.

Medical History
Is significant for head injury aged three. Seizures since age 12.

Medication
Effexor, 37.5 mg twice a day; Buspar, 10 mg t.i.d.; Trazodone, 50 mg q. h.s.; Serax, 15 mg b.i.d.; Ativan, 1 mg p.r.n.

Family History
This patient was brought up in a dysfunctional family. She used to be abused by her mother. Parents were divorced when she was 17. She completed Grade **. Currently, she is working as a *** at ***.

She has one brother who is functioning well.

Current Mental State
This patient is looking her age. She is pleasant and cooperative. Her orientation is full for time, place and person.

Her mood is depressed and sustained. Affect is flat. Thinking is logical and coherent. Thought content is informative. Cognitive functioning is intact. No obsessions, compulsions or phobias noted. She has some insight into her present state and her judgement is intact.

Assessment
Axis I -- Major depression, recurrent.
Axis II -- Deferred.
Axis III -- Head injury aged three. ? post-traumatic seizure disorder. Rule out pseudoseizures.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 55.

Plan
Discontinue Buspar, trazodone, and Serax. Increase Effexor XR to 150 mg oncea day and Ativan, 1 mg three times a day.

I will review her at my office in 1-2 weeks' time to provide her with necessary support, counselling and necessary medication management.

Edited Sample Report

This lady is well known to you and she has been complaining that she has hair on her tongue and she has been trying to scratch off the hair by constantly rubbing her tongue against her teeth.

She has been feeling quite depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do much. She is also expressing some delusional ideas about her late husband. This patient is legally blind from glaucoma.

Psychiatric History
Noncontributory.

Family History
Noncontributory.

There is no alcohol or drug abuse noted with this patient.

Current Mental State
This patient is alert and responsive. Her mood is marginally depressed. Affect is flat. Thinking is delusional.T hought content is informative. Her knowledge of recent events is limited. Her memory is not good for recent events. She could recollect things from the past fairly well. Her concentration is not good; denies any obsessions, compulsions or phobias. No hallucinations noted. She has limited insight and her judgement is only fair.

Assessment
Axis I -- Delusional disorder. Depression. Need to rule out a delerium secondary to hypoxemia associated with polycythaemia to nutritional and endocrine abnormalities contributing to the delerium.
Axis II -- Buccofacial dyskinesia ideopathic or related to atherosclerosis.
Axis III -- Rule out B₁₂, folate and thyroid dysfunction.
Axis II -- Mild psychosocial stress.
Axis V -- GAF is 55.

Plan
Agree that we discontinue haloperidol. Start her on Zyprexa, 2.5 mg q.d. Also, check her B₁₂,folate and TSH levels. If there is any abnormality, we can address that issue.

If after withdrawing her from Haldol, she continues to have symptoms of buccofacial dyskinesia, we may consider adding some free radical scavenges by way of vitamin C and vitamin E which is found to ameliorate this problem to a certain extent.

As she has polycythaemia vera rubra, a better control of this may minimize the possibility of hypoxic delerium associated with hyperviscose states.

Edited Sample Report

This patient has been feeling quite nervous, anxious, worried and depressed. She feels tired, listless, apathetic, lacking energy and ambition to do much. She is having problems sleeping on and off for the past four years.

Medication
Paxil, 20 mg q. h.s.; alprazolam, 0.5 mg q.d.; clonazepam, 2 mg q. h.s.; Rhovane, 7.5 mg q. h.s.; Novo-Tryptan, 25 mg q. h.s.; Apo-Oxybutynin, one tab q.d.; Apo-K, 600 mg q.d.

Family History
One older sister and a niece suffer from recurrent depressions.

Her mother died four years ago. Father suffers from bronchial asthma.

Personal History
Full term normal delivery. Milestones of development were normal. Completed high school. She was trained as a hairdresser. Got married at age ** and worked as a housewife most of her life. She was involved in a car accident and lost her left eye.

She has two children who are well and two grandchildren.

Medical History
Is significant for fibromyalgia. Complains that her legs hurt quite bad. She suffers from multiple aches and pains. She also has recurrent headaches.

Current Mental State
This patient is pleasant and cooperative. She is looking her age. She is alert and responsive. Her orientation is full for time, place and person. Her mood is depressed and sustained. She is quite tense and anxious. Thinking is logical and coherent. Thought content is informative. No delusional ideas noted. There is no evidence of hallucinations or other perceptual disturbances. Her sleep and appetite are disturbed.

Assessment
Axis I -- Major depression, recurrent. Benzodiazepine dependency disorder. Narcotic dependency disorder.
Axis II -- Deferred.
Axis III -- Chronic pain disorder. Fibromyalgia.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is about 60.

Plan
Discontinue Novo-Tryptan, discontinue Xanax, discontinue Rhovane. Increase Paxil to 30 mg q. h.s., Rivotril, 1 mg b.i.d. May continue MS Contin and 642 tabs p.r.n. for pain.

The plan is to get her Paxil into a therapeutic range anywhere between 40 to 60 mg a day and once we have an adequate antidepressant response, we could gradually consider reducing the dosage of Rivotril. Along with pharmacotherapy, some support and counselling, she should settle well. I will see her at my office on a few occasions.

Edited Sample Report

This patient is feeling very much better. He is calm, relaxed and at ease. His mood has improved. His concentration is good. His cognitive functioning is intact. No obsessions, compulsions or phobias noted. His sleep and appetite have improved.

He also feels that the neuropathic pain has improved over the past week to ten days.

Assessment
Axis I -- Major depression, recurrent, in partial remission.
Axis II -- Deferred.
Axis III -- NIDDM improved. Neuropathic pain associated with NIDDM improved.
Axis IV -- No stressors identified.
Axis V -- GAF is about 70.

Plan
Today, I have advised this patient to increase Zoloft to 150 mg q.d. I also advised him to keep a close eye on his blood sugars, as increased dosage of Zoloft results in decreased insulin resistance leading to a decrease in insulin requirement.

This patient is advised to keep in touch with you for ongoing follow-up. I'll review him at my office in two months' time.

Edited Sample Report

This patient is a **-year-old single male, who has been feeling quite nervous, anxious, worried and depressed on and off for the past ten years. He suffers from these episodes at least a couple of times a year. Often, he gets out of touch with reality. He gets confused, scared and starts experiencing auditory hallucinations. Often the voices tell him to do things. Other times, more than one voice starts speaking to him in his head. When he's going through these periods, he often gets quite paranoid and starts worrying somebody is going to poison him.

He was hospitalized about a year ago.

Medication
Risperidone 1 mg b.i.d.

Family History
Is significant for psychotic illness with the depressions in one of his brothers and his sister. One of his brothers, I understand, is currently a patient at **** Hospital. He tried to kill himself by taking an overdose and burning himself.

Personal History
This patient was born and brought up in ****. He has Grade *** education. He worked in his father's office as a ***. Now he's unemployed.

Current Mental State
This patient is pleasant and cooperative. He is alert and responsive. His orientation is full for time, place and person. Mood is euthymic. Affect is flat. Thinking is logical and informative. No hallucinations or delusions noted. His sleep and appetite are fair.

Assessment
Axis I -- Paranoid schizophrenia in partial remission.
Axis II -- Deferred.
Axis III -- No problems identified.
Axis IV -- Moderately-severe psychosocial stress -- financial, lack of job, etc.
Axis V -- GAF is about 55.

Plan
I have advised him to continue with risperidone, 2 mg q. h.s. I discussed with him and his family the importance of compliance with the medications. I will see him at periodic intervals for follow-up at my office.

Edited Sample Report

This patient is a **-year-old single male who has been complaining of depression, tiredness, fatigue, lack of energy and motivation to do anything over the past few months. He is constantly preoccupied with multiple somatic symptoms arranging from pain in his stomach, hands, body, shoulders, and chest. He just cannot do anything in life because of these aches and pains.

This patient is constantly sad and unhappy. He is worried about his health most of the time. He does not feel good when he gets up in the morning. He feels a bit better as the day goes by. When he is tense, he experiences a ringing noise in his ears.

Family History
Noncontributory.

Medical History
Not contributory.

Personal History
This patient was born and raised in ****. Full term normal delivery. Milestones of development were normal. He came to **** when he was 16. Initially, he found it difficult to adjust to life here. Now, he is gradually settling into the local community.

Medication
Luvox, 50 mg q.d.

Current Mental State
This patient is looking his age. He is somewhat withdrawn. He is alert. His orientation is full for time, place and person. Mood is depressed and sustained. Affect is flat. He has marked psychomotor retardation. His concentration is impaired. Cognitive functioning is intact. No obsessions or compulsions noted. No phobias or panic attacks noted. Denies any hallucinations. He has limited insight into his present state and his judgement is intact.

Assessment
Axis I -- Major depression, recurrent. Rule out somatization disorder.
Axis II -- Deferred.
Axis III -- No problems identified.
Axis IV -- Moderate psychosocial stress.
Axis V -- GAF is 50.

Plan
Discontinue Luvox. Start on Serzone, 100 mg b.i.d. and increase the dosage of Serzone to 300 to 400 mg a day based on his tolerance and response. I will review him at my office in 2-3 weeks' time for necessary support and counselling.

Edited Sample Report

This patient is a **-year-old female who has been feeling quite depressed, sad, unhappy, withdrawn, apathetic, lacking energy and ambition to do much over the past few years. She is married to an alcoholic and had difficulty getting along with him. She ended up separating from him for a period of time only to get back with him about a year ago. Over and above this, she is also confronted with financial problems.

Psychiatric History
Is significant for recurrent depressions since childhood.

Family History
Is significant for depression with her mother. One sister and brother also suffer from recurrent depressions.

Personal History
This patient was born and brought up in ****. Full term normal delivery. Milestones of development were normal. Uneventful childhood. Got married in **** and had two kids by the time she came to **** 1981.

Medical History
Noncontributory. No alcohol or drug abuse noted.

Medication
None.

Current Mental State
This patient is alert and responsive. Her orientation is full for time, place and person. Her mood is depressed and sustained. Energy level is low. Concentration is impaired. She has diurnal variation of mood changes. She is also showing signs of psychomotor retardation. Her cognitive functioning is intact. She is of average intelligence. No obsessions, compulsions or phobias noted. Sleep and appetite are disturbed.

Her sex drive is quite low.

Assessment
Axis I -- Major depression, recurrent with anger attacks. Premenstrual dysphoric disorder.
Axis II -- Deferred.
Axis III -- No problems identified.
Axis IV -- Moderately-severe psychosocial stress, financial.
Axis V -- GAF is about 60.

Plan
Start on Zoloft, 50 mg into one week, then increase the dosage to 100 mg q.d. along with Rivotril, 0.25 mg q. h.s.

I will review this patient at my office in 3-4 weeks' time. She is advised to keep in touch with you for periodic follow-up and renewal of her medications.