Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 16
Description: Short-term memory loss (probable situational) and anxiety stress issues.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke.
CURRENT MEDICATIONS: Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily.
ALLERGIES TO MEDICATIONS: Naprosyn.
SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker. Please see notes dated 06/28/2004.
REVIEW OF SYSTEMS: Review of systems is otherwise negative.
Vital Signs: Age: 60. Weight: 192 pounds. Blood pressure: 134/80. Temperature: 97.8 degrees.
General: A very pleasant 60-year-old white female in no acute distress. Alert, ambulatory and nonlethargic.
HEENT: PERRLA. EOMs are intact. TMs are clear bilaterally. Throat is clear.
Neck: Supple. No cervical adenopathy.
Lungs: Clear without wheezes or rales.
Heart: Regular rate and rhythm.
Abdomen: Soft nontender to palpation.
Extremities: Moving all extremities well.
1. Short-term memory loss, probable situational.
2. Anxiety stress issues.
PLAN: Thirty-minute face-to-face appointment in counseling with the patient. At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn. The current job she is at does sound extremely stressful and demanding. I think her stress reactions to these as far as feeling frustrated are within normal limits. We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc. She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation. I did spend quite a bit of time reassuring her as well. She is currently on Zoloft 100 mg which I think is an appropriate dose. We will have her continue on that. She did verbalize understanding and that she actually felt better after our discussion concerning these issues. At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels. She is going to think about that.
Keywords: consult - history and phy., short-term memory loss, anxiety, short term memory loss, memory loss, stress issues, situational, memory, stress,