Sample Name: Gen Med Consult - 15
Description: Complaint of mood swings and tearfulness.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.
FAMILY HISTORY: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.
ALLERGIES: She is allergic to Sulfa.
CURRENT MEDICATIONS: Recently finished Minocin and Duraphen II DM.
General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.
Eyes: PERRLA. Conjunctivae are clear.
Neck: Supple with adenopathy or thyromegaly.
Heart: Regular rate and rhythm without murmur.
1. Postsurgical menopause.
2. Mood swings.
Keywords: general medicine, tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,