Psychiatric – Medical Transcription Phrases, Words, And Helpful Hints

Schizophrenia Discharge Summary Transcription Sample Report

Admin — Sat, 30 May 2020 13:41:24 +0000

Schizophrenia Discharge Summary Transcription Sample Report

DISCHARGE DIAGNOSES:

AXIS I: Schizophrenia, paranoid type; polysubstance abuse, alcohol and crack, currently in remission.

AXIS II: Deferred.

AXIS III: New-onset diabetes type 2.

AXIS IV: Financial stress, unemployment, currently in rehab, chronic mental illness.

AXIS V: Global assessment of functioning on admission 25. Global assessment of functioning on discharge 50.

PROCEDURES PERFORMED: MRI of the head was performed with and without contrast. It showed prominent nasopharyngeal tissue with internal cysts, more prominent on the left, and probable prominent adenoidal tissue, including Tornwaldt cyst, a slightly tortuous left vertebral artery minimally indented in the left medulla and minimal prominence of the right temporal horn when compared to the left, which is most likely a normal variation. Otherwise, normal brain MRI.

CONSULTANTS:

1. Physical therapy.

2. ENT.

3. Endocrinology.

ALLERGIES: No known drug allergies.

DISCHARGE MEDICATIONS:

1. Wellbutrin 100 mg p.o. b.i.d.

2. Metformin 500 mg p.o. b.i.d.

3. Risperdal 3 mg p.o. b.i.d.

4. Trazodone 200 mg p.o. at bedtime.

5. Naprosyn 500 mg p.o. b.i.d. p.r.n. for pain or headache.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a history of schizophrenia and polysubstance abuse referred by his case manager due to increased hallucinations, including auditory, and new onset of olfactory, gustatory and tactile hallucinations. Since the onset of the hallucinations, the patient has become acutely suicidal with multiple plans. He has a history of polysubstance abuse with alcohol and crack but has been sober for greater than 3 months and has been in rehab. He also complains of headaches recently. The patient, with history of schizophrenia, presented frightened, tearful and continued to endorse suicidal thoughts.

PAST PSYCHIATRIC HISTORY: Paranoid schizophrenia, substance abuse.

PAST MEDICAL HISTORY: Left shoulder injury with chronic pain and a seizure one time in the past.

FAMILY HISTORY: The patient does have a brother with schizophrenia and a mother who died from complications of diabetes.

SOCIAL HISTORY: The patient currently is in rehab. Divorced. Did finish high school and went to junior college for a little while but did not get a degree. He has been unable to hold a steady job for most of his life.

REVIEW OF SYSTEMS: Included headache and some blurry vision. He denies constitutional symptoms. He denied chest pain, difficulty breathing, GI symptoms, dysuria. He does endorse left shoulder pain. He denied any skin conditions and he does endorse numbness of his distal feet.

MENTAL STATUS EXAMINATION: Appearance and Behavior: He had good eye contact, well groomed, fair hygiene. Speech and Language: Normal volume, tone and rate, nonpressured. Mood and Affect: Mood was depressed and affect was congruent and restricted. Thought processes linear and goal directed. Though Content: He does have some paranoia believing that people, including the doctors, are experimenting on him. HI/SI: He denies currently having suicidal ideations. Perceptual Abnormalities: He reports visual, auditory, gustatory and tactile hallucinations. Orientation: He is alert and oriented x3. Memory and abstractions are fair. Fund of knowledge and IQ are average and insight and judgment are limited and poor. His initial physical exam was significant for pain and decreased range of motion in the left shoulder on passive abduction and extension and a mild paresthesia of the plantar surface of his right second toe; otherwise, neurologic exam was normal.

LABORATORY DATA: Initial labs included a CBC, which was within normal limits. Electrolyte panel showed sodium of 133, potassium of 4.1, chloride 100, bicarb 27, BUN 13, creatinine 1.1 and a random glucose of 291 with calcium of 9. LFTs were within normal limits. Total cholesterol was 145, HDL 44, LDL 92, triglycerides 49. TSH within normal limits.

HOSPITAL COURSE:

1. The patient was evaluated and treated by the multidisciplinary treatment team including physicians, nurses, social workers and therapists. All medications were presented to the patient and he gave written consent to all the medications he was given, as well as was explained the risks, benefits, side effects and alternatives of all medication therapies. The patient was integrated in some milieu on the ward and encouraged to attend to his ADLs and participate in groups.

2. Schizophrenia: On admission, the patient’s Risperdal was gradually titrated up to a goal dose of 3 mg twice a day prior to discharge. He tolerated the medication well with no significant side effects and reported that his hallucinations significantly improved. He denied psych symptoms prior to discharge. The patient presented as very organized in his thoughts, linear, logical and appropriate. He did not have any behavioral or management problems while in the unit and participated in groups very well with good interactions with staff and peers, as there has been some question whether the patient also has a mood component of his psychiatric disease. His trazodone was increased to 200 mg at bedtime to help with sleep and his Wellbutrin was maintained at his home dose. His mood improved throughout hospitalization as well, and he was euthymic with appropriate affect prior to discharge. The patient did have neuro psych testing done while in the hospital. Results are pending at the time of discharge.

3. Diabetes: The patient was diagnosed with new onset of diabetes during this hospitalization. A hemoglobin A1c was sent, which came back elevated at 8.7. He also had a fasting glucose done, which was elevated at 216. Given that the patient met criteria for diabetes, endocrine was consulted and agreed with the plan to start patient on a low dose of metformin and titrate it up to a goal of 500 mg twice a day prior to discharge. The patient tolerated the metformin well and his blood sugars came under good control. His blood glucoses prior to discharge were 98 and 106 respectively. He was maintained on a sliding scale insulin as needed for increased blood sugars; however, the glucose seemed to be well controlled with just the oral hypoglycemic agent. The patient’s headaches also seemed to resolve once he was well hydrated and his blood sugars were under control. He will follow up with the endocrine clinic in 2 to 3 weeks for management of his diabetes and outpatient referral form was faxed and the patient was instructed to follow up with an appointment.

4. Shoulder pain: The patient has had left shoulder pain, which appears to be a frozen shoulder versus a rotator cuff tendinitis. We continued him on Naprosyn as needed for shoulder pain. We also consulted physical therapy, who were able to provide him with several exercises to improve his range of motion and pain in his shoulder. The patient was very agreeable with completing the exercises and claims to continue doing them as an outpatient.

5. Nasal cyst: An incidental finding on MRI was Tornwaldt cysts. ENT was consulted and recommended that he follow up as an outpatient as these are usually benign and most likely just an incidental finding and do not have any pathological significance. He should follow up if he has any further questions or concerns.

6. Disposition: The patient was initially on a 72-hour hold and was able to sign in voluntarily to the hospital. He was provided with diabetes education prior to discharge and he was to go back to rehab until he completes the program there.

DISCHARGE CONDITION: Good.

DISCHARGE INSTRUCTIONS:

1. Diet: ADA diabetic diet.

2. Activity: Ad lib with continuing of the exercises for his left shoulder.

3. Take medications as prescribed and not making any changes without first consulting with his outpatient doctor.

4. He was advised to avoid substances as he has been sober now for greater than 3 months.

5. He should follow up with endocrine clinic.

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Psychiatric Evaluation Medical Transcription Sample Report

Admin — Thu, 21 May 2020 12:49:31 +0000

IDENTIFYING AND BACKGROUND DATA: The patient is an (XX)-year-old Caucasian girl with a history of several placements in foster homes and long-term conflicts with her biological mother, who was cited for neglect regarding the patient and her sister. The patient is here for psychiatric evaluation.

Staff and the patient both feel the best disposition plan for her is to be referred to foster care, though she has been visiting her mother and still considers that an option upon discharge.

She has not been on psychotropic medication though it has been considered and recommended in the past for depression. She has a history of, at times, being out of program and oppositional to authority figures and is described as easily influenced by her peers seeking positive reinforcement from adults that was not forthcoming at home.

The patient was evaluated by us MM/DD/YYYY. At that time, plans were to eventually attend foster care, and psychotropic medication was not indicated, as she had been in reasonable control.

For further history and background information, please refer to the record and past psychiatric evaluation.

PSYCHIATRIC INTERVIEW: The patient was friendly in the interview, and her mood was upbeat. She denied any recent depression and stated she had no appetite or sleep disturbances.

She said at this time the plan was to be referred eventually to a foster home or possibly to her mother. She said she hoped to be discharged within two months.

She said her behavior had been in reasonable control, and she had been doing well in school. She denied any substance abuse. She denied any suicidal or assaultive ideation.

She stated that she had a few friends here, and no romantic relationships currently, but this was not important to her at this time.

She stated her main hobby at this time is music, and in the future, she hopes to have a job as a radiologist. Her thinking was goal directed, and there was no presence of hallucinations or any psychotic phenomenon.

DIAGNOSTIC IMPRESSION:

AXIS I: Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Improved.

AXIS II: Deferred.

AXIS III: No major medical illnesses other than acne.

AXIS IV: Past Stressors – Severe, conflict with mother, history of maternal neglect, repeated failed foster home placements.
Current Stressors – Moderate, upcoming plan for discharge from (XX) to probable foster placement.

AXIS V: GAF in current institutional setting: 60.

RECOMMENDATIONS: The patient continues to be considered for referral to foster care.

Upon discharge, she should receive supportive counseling, which would include giving her vocational direction in her area of interest and ongoing meetings to stabilize her relationship with her mother.

Psychotropic medication is not currently indicated, but should be considered in the future if mood or behavioral behaviors worsen.

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Psychiatric and Mental Status MT Words and Phrases For MTs

Admin — Fri, 21 Feb 2020 17:52:04 +0000

Psychiatric and Mental Status MT Words and Phrases For MTs

Explanation of Axis I to V:

Axis I: Clinical disorders, syndromes and/or other areas of concern

Axis II: Personality disorders and mental retardation

Axis III: Medical conditions (which may impact emotions)

Axis IV: Psychosocial stressors (death, divorce, loss of job, etc.)

Axis V: Global assessment of functioning.

Psych Sample Report # 1 Psych Sample Report # 2

COMMON PSYCHIATRIC/MENTAL STATUS PHRASES AND WORDS:

3-step command

able to spell “world” backwards

able to provide a correct year, month, date, day of the week, correct state, city

able to recite alphabet correctly in a timely manner and count backwards

able to maintain attention on the task at hand

able to name 2 out of 2 common objects and 5 out of 5 body parts

able to comprehend presented questions and commands correctly

ankle jerks

able to name objects, repeat phrases

able to process information

able to recall 3 out of 3 words

able to spell the word “world” backwards

adjustment disorder with depressed mood

adjustment disorder with depressed mood, in full remission

adjustment disorder with diminished mood

adjustment disorder with mixed anxiety and depression

affect was appropriate to content and normal in range

affect was blunted / affect was full range

affect was tearful / affect was euthymic

alcohol-induced psychotic disorder with hallucinations

all three spheres / all 3 spheres

anhedonia

antisocial behavior

antisocial traits (personality disorder with antisocial traits)

apathy, indifference

aphasia

appears detached and aloof

ataxia

attention and concentration

attention deficit hyperactivity disorder, combined type

auditory or visual hallucinations

awareness of current events

bipolar affective disorder, type II

borderline personality disorder with obsessive-compulsive features

bradykinesia

bradyphrenia, bradykinesia, rigidity, psychomotor slowing

Broca’s aphasia

buccofacial and ideomotor apraxia

capacity for self-introspection

chronic schizophrenia, paranoid type

chronological order

cluster B traits

cocaine-induced mood disorder

cogwheeling, rigidity, spasticity

command hallucinations

constricted affect

conversion disorder

coordination and gait are intact

deep tendon reflexes are brisk and equal

delayed grief

delusional

demonstrated good recall

depressive disorder, not otherwise specified (NOS = not otherwise specified)

despondent

difficulty establishing and switching cognitive sets

disheveled

dysarthria

dysgraphia

dyskinetic movement

dysnomia, jargon or paraphasic errors

dysphoric mood

dysthymic disorder

emotional dyscontrol, lability, over-excited behavior and irritability

expressive and receptive language

expressive aphasia

flight of ideas

Folstein Mini Mental status Exam

formal thought disorder

frontal release signs such as sucking, snout reflex, grasp, palmomental reflex, nuchocephalic and self-grasping were not elicited on testing

fund of knowledge

fund of general knowledge

gait is narrow based or wide based

glabellar reflex

good vocabulary

grandiose and expansive

grandiose ideation

grandiosity

grip strength

groomed

hallucinatory disturbances

hygiene and grooming (are fair / good / poor, etc)

hypothetical judgment

ideas of reference

illusionary experience

immediate recall / short-term recall

impulse control

impulse control disorder, not otherwise specified

impulsive reasoning

impulsivity, disinhibition

incoherent

insight and judgment

intermittent explosive disorder

internally preoccupied

judgment and problem-solving abilities

knee jerks

knows the city and state

limited vocabulary

letter perception was intact

loosening of association or flight of ideas

maintains eye contact / does not maintain eye contact

major depressive disorder

major depressive disorder, recurrent

memory abstractions

mental status is intact in all four spheres

mood appears depressed

mood was labile

narcissistic and histrionic features

narcissistic personality disorder with antisocial traits

new learning and delayed recall

no field cut to gross confrontation

no strange or odd posturing or mannerism

noncommand hallucinations

nonpressured speech

normal tone, bulk and power in all extremities

Novel motor programming

object perception

opioid-induced anxiety disorder

oriented to time, place, and person

palate moves symmetrically

palate moves up in the midline

panic attack

panic disorder

panic disorder without agoraphobia

paranoid

paranoid ideations

paresthesias

passive death wishes

paucity of thought

perceptual abnormalities

persecutory delusions

persecutory ideas of reference

perseverations or stimulus bounded behavior

plantar reflexes are flexor bilaterally

plantar responses

poor historian

postictal confusion

posttraumatic stress disorder (PTSD)

postural tremor

poverty of content

poverty of speech

prodromal symptoms of schizophrenia

proverb interpretation is concrete

proverb interpretation is fair

psychomotor dysfunction

psychopathology

psychotic symptoms

psychotic disorder, not otherwise specified

pupils are _____ (2, 3, or 4) mm and reactive

rapport seemed adequate

rate, volume and prosody of speech

reaction time to questions

reality testing was intact

recent and remote memory

recognition of low-level words

redirectable

reduplicative paramnesia

remembered 0/3 objects after 5 minutes

remembered 1/3 objects after 5 minutes

remembered 2/3 objects after 5 minutes

remembered 3/3 objects after 5 minutes

response to internal stimuli

responses were linear

restraints

Romberg

schizoaffective disorder, bipolar type

schizophrenia, paranoid subtype

schizophreniform disorder

sense of hopelessness

sensorium

Sensory exam: All modalities are intact

serial 3s

serial 7s

shoulder shrugs

social phobia

somatic conversion symptom

somatic delusions

speech was clear, coherent, and goal directed

speech was normal rate, tone, volume

speech was rambling

staring into space

stream of mental activity was logical, relevant, coherent

stressors

suicidal or homicidal ideation

suicidal or homicidal ideas

switching cognitive sets

tactile discrimination

tangential thoughts

thought process was goal directed

thought blocking

thoughts, plan or intent (eg – suicidal or homicidal thoughts, plan or intent)

tongue protrudes to the midline

trend of thought

trouble with word finding

unintelligible and illogical

unresolved grief

uses rationalization and denial to explain

verbally contract for safety

vision was notable for floaters

visual fields are full to threat

visual fields were full and tactile localization was intact

visual withdrawal

visuoconstruction and visuomotor integration

voluminous details

Wernicke’s aphasia

word salad and loose associations

word substitution

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