Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Psychosis

Description: Patient with a history of PTSD, depression, and substance abuse.
(Medical Transcription Sample Report)


HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior. Recently, she was picked up by Kent Police Department "leaping on Highway 99."

PAST MEDICAL HISTORY: PTSD, depression, and substance abuse.




REVIEW OF SYSTEMS: Unable to obtain secondary to the patient being in seclusion.

OBJECTIVE: Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit. General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.

LABORATORY DATA: Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2. Previous urine tox was positive for THC. Urinalysis was negative, but did note positive UA wbc's. CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.

AXIS I: Psychosis. Inpatient Psychiatric Team to follow.
AXIS II: Deferred.
AXIS III: We were unable to perform physical examination on the patient today secondary to her being in seclusion. Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI. We will wait until the patient is out of seclusion to perform examination. Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy. We will followup with the patient should any new medical issues arise.

Keywords: consult - history and phy., ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples