Medical Specialty: Radiology
Sample Name: Angiogram & StarClose Closure

EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.
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DESCRIPTION: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.

radiology, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral,

The situation described involves a detailed medical examination and procedure related to the cardiovascular system, specifically focusing on the coronary arteries. The findings suggest the presence of blockages in the arteries, which can have serious implications for the patient's health and may require intervention such as elective PCI (Percutaneous Coronary Intervention). These procedures involve risks and are critical for diagnosing and planning treatment for potentially life-threatening heart conditions, indicating a high-stakes situation.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Radiology
Sample Name: 2-D Echocardiogram - 2

1.  The left ventricular cavity size and wall thickness appear normal.  The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  There is near-cavity obliteration seen.  There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2.  The left atrium appears mildly dilated.,3.  The right atrium and right ventricle appear normal.,4.  The aortic root appears normal.,5.  The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  Estimated pulmonary artery systolic pressure is 49 mmHg.  Estimated right atrial pressure of 10 mmHg.,8.  The pulmonary valve appears normal with trace pulmonary insufficiency.,9.  There is no pericardial effusion or intracardiac mass seen.,10.  There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,
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DESCRIPTION: 2-D Echocardiogram

2-D Echocardiogram

radiology, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery

The situation describes findings from a 2-D echocardiogram, which is a common test used to assess heart function. The results show a mix of normal findings and potential concerns such as mild mitral regurgitation, aortic valve stenosis, and possible hypertrophic changes. However, there is no immediate life-threatening condition described. While these findings require follow-up and potential treatment plans, especially regarding the stenosis and elevated pressures, they do not indicate an acute emergency. The stakes are moderate, as these conditions can lead to serious issues if not managed, but they are not immediately life-threatening.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: 3-Dimensional Simulation

3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.
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DESCRIPTION: 3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.

radiology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare 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 beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

3-dimensional simulation for planning radiation therapy is crucial as it affects the precise targeting of the tumor while sparing healthy tissue, impacting the effectiveness of cancer treatment and minimizing side effects. This precision is vital for patient outcomes and safety, making the situation relatively high-stakes. The procedure also involves significant effort and coordination among medical professionals, further indicating its importance.


Medical Specialty: Radiology
Sample Name: 2-D Echocardiogram - 4

DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,
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DESCRIPTION: Echocardiogram and Doppler

Echocardiogram and Doppler

radiology, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve

The echocardiogram results indicate mostly normal findings, with normal cardiac chamber size and normal valve motions. The ejection fraction, a key indicator of heart health, is within the normal range at 60%. While there are mentions of trace mitral and tricuspid regurgitation, these are minimal findings that do not raise significant immediate concerns. In the context of radiology and cardiology, an echocardiogram report like this generally does not indicate a high-stakes situation unless the patient has additional risk factors or symptoms. Therefore, while any medical discussion can carry a degree of importance, this particular set of results suggests low urgency or risk based on the information provided.


Medical Specialty: Psychiatry / Psychology
Sample Name: Recheck of ADHD Meds

SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.
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DESCRIPTION: A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

psychiatry / psychology, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,

This situation involves a young child being treated for ADHD with medication. The stakes are moderately high because it concerns the child's well-being, academic performance, and overall quality of life. Adjusting medication in children requires careful consideration due to potential side effects and the implications on development. However, since the patient is already showing improvement and a plan for adjustment is discussed, it is not extremely high-stakes, but rather a manageable medical situation.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychological Testing

REFERRAL QUESTIONS:,  Mr. Abcd was referred for psychological assessment by his primary medical provider, to help clarify his diagnosis, especially with respect to Attention Deficit Hyperactivity Disorder, a depression, or a Bipolar Spectrum Disorder.  The information will be used for treatment planning.,BACKGROUND INFORMATION:,  Mr. Abcd is a 33-year-old married man who lives with his wife and three children.  He has been married since 1995 and lost a son to SIDS over seven years ago.  He served in the army for two years, and did attend some college at UAA.  He still wants to get a degree in engineering.  Mr. Abcd indicated that he did use THC at the time of his initial intake with me in January 2006, but there are no other substance abuse issues as an adult so far as I am aware.  He has had multiple stressors, including a bankruptcy in 2000, as well as his wife's significant health problems.  He also reported having herniated discs incurred in an injury over a year ago.  He has received counseling in the past, and did try both Lexapro and Wellbutrin, which he stopped taking in October 2005.  He indicated these medications tended to decrease libido and flatten all of his emotions.  He indicated that he thought he might have Attention Deficit Hyperactivity Disorder, but that this had not been formally evaluated or treated.  There is no reported bipolar illness in his immediate family, but there is some depression.  A recent stressor involved OCS involvement, apparently because his infant child tested positive for THC.  So far as I am aware, this case is closed at this time.  ,BEHAVIORAL OBSERVATIONS:,  Mr. Abcd arrived on time for his testing session dressed casually and with good hygiene and grooming.  Mood is reported to be generally okay, though with some stress.  Affect was bright and appropriate to the situation.  Speech was a little pressured, but was of normal content and was at all times coherent and goal directed.  He was a very pleasant and cooperative testing subject, who appeared to give a good effort on the tasks requested of him.  The results appear to provide a useful sample of his current attitudes, opinions, and functional levels in the areas assessed.,ASSESSMENT RESULTS:,  Mr. Abcd's responses to a brief self-report instrument given to him by Dr. Starks was suggestive of symptoms that could be consistent with Attention Deficit Hyperactivity Disorder.  I therefore had him complete the Conners CPT-II, which showed good performance and no indications of attention problems.  The Confidence Index associated with ADHD was over 58 percent that no clinical attention problems are present.  While a diagnosis of Attention Deficit Hyperactivity Disorder should not unequivocally be ruled out based on the results of this test, there is nothing in the CPT-II measures indicating attention problems, and that diagnosis appears to be unlikely.  The MMPI-2 profile is a technically valid and interpretable one.  The Modified Welsh Code is as follows:  49+86-231/570:  F'+-/:LK#.  The high F scale may reflect some moodiness, restlessness, dissatisfaction, and changeableness in his typical behavior.  The Basic Clinical Profile is similar to persons who tend to get into trouble for violating social norms and rules.  Such persons are more likely to experience conflicts with authority.  They also are prone to impulsivity, self-indulgence, problems with delay of gratification, exercise problematic judgment, and often have low frustration tolerance.  Those with similar scores tend to be moody, irritable, extraverted, and often do not trust others very much.  Mr. Abcd may tend to keep others at a distance, yet feel rather insecure and dependent.  A bipolar diagnosis is a possibility, and an antisocial personality disorder cannot be entirely ruled out either, though I am less confident that that is correct.  The MMPI-2 Content Scale scores indicate some mild depression and family stressors, and the Supplementary Scales has a single clinical elevation on Addiction Admission, which is entirely consistent with his interview data.  Posttraumatic stress scales are not elevated at a clear clinical level on the MMPI-2.,SUMMARY AND RECOMMENDATIONS:,
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DESCRIPTION: Psychological Testing for ADHD

Psychological Testing for ADHD

psychiatry / psychology, psychological testing, adhd, attention deficit hyperactivity disorder, bipolar spectrum disorder, cpt-ii, mmpi-2, posttraumatic stress disorder, welsh code, depression, psychological assessment, personality disorder, family stressors, posttraumatic stress, disorder, attention, psychological,

The situation involves a psychological assessment to clarify the diagnosis of a patient experiencing potential ADHD, depression, or bipolar spectrum disorder. Diagnoses will inform treatment planning, which is important for the patient's mental health and daily functioning. However, it is not a life-threatening immediate crisis, such as an acute mental health episode that requires immediate intervention to prevent harm to self or others. Therefore, while the outcome of the assessment is significant for the patient's long-term treatment and quality of life, it doesn't necessarily constitute a high-stakes situation in the sense of urgent or critical medical situations.


Medical Specialty: Radiology
Sample Name: 2-D Doppler

2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.
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DESCRIPTION: Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.

radiology, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,

The scenario involves interpreting a radiology report concerning heart conditions such as aortic stenosis, ventricular hypertrophy, and atrial enlargement. While the findings are relatively mild to moderate and do not indicate any immediate life-threatening issues, they do require careful monitoring and management to prevent potential complications. Therefore, the stakes are moderate due to the potential implications for the patient's health over time.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Discharge Summary - 2

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.
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DESCRIPTION: Discharge summary of a patient with depression and high risk behavior.

The document is a discharge summary for a psychiatric patient with depression and high-risk behavior, which indicates that the patient may have been a danger to themselves or others. Discharging such a patient involves ensuring they have adequate support and follow-up care to prevent any negative outcomes. The situation is high-stakes because it involves mental health, safety, and the potential for harm if the patient is not properly managed post-discharge. The involvement of the family also adds complexity, as their support is crucial in the patient's recovery process.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Evaluation - 2

IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:,  Depression.,HISTORY OF PRESENT ILLNESS:,  The patient's depression began in her teenage years.  Sleep has been poor, for multiple reasons.  She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  The patient tends to feel irritable, and has crying spells.  She sometimes has problems with motivation.  She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change.  Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine.  She does not have suicidal thoughts.  ,The patient also has what she describes as going into a "panic mode."  During these times, she feels as if her whole body is going to explode.  She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  These spells may last a couple of hours, but once lasted for about two day.  She does not get chest pain.  These attacks tend to be precipitated by bills that cannot be paid, or being on a "time crunch." ,PSYCHIATRIC HISTORY:,  The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking.  Although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times.  At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  She has never been hospitalized for psychiatric purposes.  She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine:  The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco:  She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day.  She is still committed to quitting.,Alcohol: Denied.,Illicit drugs:  Denied.  In her earlier years, someone once put some unknown drug in her milk, and she "came to" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional:  See History of Present Illness. No recent fever or sweats.
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DESCRIPTION: Psychiatric evaluation for major depression without psychotic features.

The situation presented is a psychiatric evaluation that indicates the patient is experiencing long-term depression, anxiety attacks, and has a history that includes a past self-harm incident. While the patient does not currently express suicidal thoughts and there's no immediate threat to her life, the situation involves ongoing mental health issues that can significantly affect her quality of life. Additionally, there are concerns about the patient's compliance with medical devices essential for managing co-morbid conditions like sleep apnea. However, it doesn’t involve immediate life-threatening conditions or urgent psychiatric crises. The high stakes revolve around managing her mental health effectively to avoid potential escalation.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Evaluation - 4

ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA:  ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister.  She also has a stepsister that is 8 years old.  The patient was brought in by her mother after being picked up by Anchorage Police Department (APD).  She was brought to our institution for an assessment.  ,REASON FOR ADMISSION/CHIEF COMPLAINT:  ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then.  Her friends report to the parents that she is suicidal and that she had a knife.  A friend took a knife away from her to keep her from cutting herself.  ,HISTORY OF PRESENT ILLNESS:  ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents.  This is her first admission.  APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal.  The mother found journals in her room talking about suicide, and that she has been raped.  There were no details and the client denies that she was raped.  She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year.  She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage.  She reports symptoms of depression, no energy, initial and middle insomnia, eating more.  She is very irritable and has verbal altercations wither sister who is 14.  She admits to being sad and also having poor concentration.  She had marked drop in school functioning in the last year, and will need to repeat the ninth grade.  The mother is very concerned with the patent's safety and feels she is not able to control her.  She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican.  She went to live with her dad up to age 16.  Now she is living with her mother and her mother's boyfriend for the last two months.  In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY:  ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY:  ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family.  ,FAMILY PSYCHIATRIC HISTORY:  ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY:  ,She was born with some eczema.  At age 4 she was involved in an accident where she cut one of her legs and needed sutures.  There is no history of seizure or head injury.  She reports loss of consciousness.  This will be investigated; there are no details about it.  She admits to being sexually active, protecting herself using condoms.  Her last menstruation period was 07/20/04.  ,ALLERGIES:  ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema.  Early milestones walk and talk.  The patient appears to function at the expected age level.  ,PERTINENT PSYCHOSOCIAL DATA:  ,Complete pertinent psychosocial will be obtained by our clinician.  The patient admits witnessing seeing some domestic violence when she was small, around five years old.  There is an allegation of a rape that the mother found in her journal, but this is going to be investigated.  ,SCHOOL HISTORY:
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DESCRIPTION: Admission Psychiatric Evaluation

Admission Psychiatric Evaluation

This situation is high-stakes due to several critical factors: the adolescent has exhibited suicidal behavior and has been on the run, which indicates a significant risk to her safety. The involvement of the police and the presence of a knife highlight the immediate threat of self-harm or potential harm to others. The history of reported depression, the distressing personal and family background, and the current unstable living situation further compound the seriousness of her mental health condition. These elements make it imperative that she receives immediate and appropriate psychiatric intervention to ensure her safety and welfare.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Evaluation - 1

IDENTIFYING DATA:,  The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:,  The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:,  The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D.  Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works.  He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder.  Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful.  In the past, probably in high school, the patient recalled being more figidity than now.  He tensed to feel anxious.  Sleep has been highly variable.  He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month.  Appetite has been good.  He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall.  He tends to feel depressed.  His energy level is "better now," but this was very problematic in the past.  He has problems with motivation.  In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:,  The patient has never been hospitalized for psychiatric purposes.  His only treatment has been at this facility.  He tried Adderall for a time, and it helped, but he became hypertensive.  Lunesta is effective for his insomnia issues.  Effexor has helped to some degree.  He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success.  He sometimes takes the other half of the tablet in the afternoon.
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DESCRIPTION: Patient with a long history of depression and attention deficits.

The situation involves a psychiatric evaluation for a patient with a long history of depression and attention deficit issues. Although there are concerns about past suicidal thoughts, the patient states this is no longer an issue. The patient is also managing his condition with medications and has not been hospitalized for psychiatric purposes. Given these factors, while mental health is important, the immediate situation doesn't appear life-threatening or extremely high-stakes. However, ongoing management and monitoring are crucial.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Discharge Summary

DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.
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DESCRIPTION: The patient was discharged by court as a voluntary drop by prosecution.

psychiatry / psychology, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,

The discharge summary presents a concerning situation involving a patient with a severe psychiatric disorder, schizoaffective disorder, who was discharged against medical advice due to legal intervention. The patient's condition appears unresolved, with symptoms like disorganization, anxiety, and paranoid delusions still present. The discharge, managed as a result of court decisions rather than medical readiness, could pose significant risks to the patient's well-being and potentially the safety of others, depending on how she interacts with her environment. Discharge without ongoing, supervised care represents a high-stakes situation given her mental health condition and the challenges noted in the report.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Evaluation - 3

IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr.  Circumstances leading to this admission:  In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h.  Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper.  ABCD is also complaining of headaches when he takes the medication.  Mother reports that on the weekends he is off the medication.  She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, "It's an accident."  She sees him as impulsive on the weekends, but is not sure if this just isn't "all boy.",Mother reports ABCD has been on medication since kindergarten.  Currently, the teachers say he is able to pay attention and he is well behaved in school.  Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct.  He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep:  As stated before, he is having much difficulty on a consistent basis falling asleep.  It is 12:00 to 1:00 a.m. before he falls to sleep.  When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty.  On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite:  He will eat breakfast and supper, but not much lunch, if any at all.  He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control:  Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior.  The only exception to this is he gets in occasional fights with his sisters.  ABCD denies visual or auditory hallucinations or racing thoughts.  He reports his thoughts are sometimes bad because he says sometimes he thinks of the "S" word.,Energy:  Mother reports a lot of energy.,Pain:  ABCD denies any pain in his body.,Suicidal or homicidal thoughts:  He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06.  He has received outpatient therapy from XYZ, LCSW.  He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar.  She reports she has significant moodiness episodes and believes in the past she has had a manic episode.  She is currently not on medication.  She does not know of anyone else in her family, with the exception of she said her father's behavior was "weird."  Biological father's side of the family, mother reports father was very impulsive.  He had anger issues.  He had drug and alcohol issues.  He was in jail for three years for risky behavior.  There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years.  They divorced when ABCD was 2-1/2 years of age.  Currently, father has been deported back to Mexico.  He last saw ABCD in March 2006 for one day when they went down to AAAA.  He does call on special holidays and his birthday.  Contact is brief, but so far has been consistent.  Mother is currently seeing R, a significant other, and has been seeing him for the last seven months.  ABCD had a good relationship with R.  ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as "all wisdom.",PREGNANCY:,  Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero.  She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:,  Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:,  Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:,  Mother reports ABCD was a very cuddly infant and could sleep well.  As a toddler, he was all over the place, climbing and always busy.  Elementary school:  In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen.  ABCD has no history of fire setting or abuse to animals.  He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:,  Noncontributory.,MEDICAL STATUS AND HISTORY:,  ABCD has no known drug allergies.  He has no history of heart murmur, heart defect of other heart problems.  No history of asthma, seizures or head injuries.  He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:,  When I asked ABCD whether he likes school, he stated, "No."  His grades are okay, per mother.  He does have an IEP for the ADHD, but she does not believe he has a learning disability.  Behavior problems:  He currently is not having any behavior problems in the school.  He reports he does not get along with his teachers because they tell him what to do.  Strengths:  He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:,  He reports he has best friends.  He named two, D and B, and he does have a friend that is a girl named Kim.  When asked if church or God were important to him, he stated, "God is."  He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:,  In the home, he has chores of taking out the trash.,LEGAL:,  He has not been involved in the legal system.,SUPPORT SYSTEMS:,  When asked if he feels safe in his home, he stated, "Yes."  When asked who he talks to if he is hurt or upset, he stated, "Mom."  (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:,  He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:,  This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions.  ABCD kept himself occupied throughout and was very well behaved throughout the session.  He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes.  Distractibility and attention:  He, at times, was very mildly distracted, but otherwise did not appear hyperactive.  His judgment was adequate.  When asked what he would do if there was a fire in his house, he said, "Get out!"  Insight was poor to adequate.  Fund of information was good.  When asked who the president was, he said, "George Washington." Intelligence is probably average to above average.  Speech was normal.  He had some difficulty with abstract thinking.  He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle.  On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly.  When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly.  Appearance was casual.  Hygiene was good.  Attitude was cooperative.  Speech was normal.  Psychomotor was between normal and slightly hyperactive.  Orientation was x2.  Attention/concentration was intact.  Memory was intact at times and then had some memory recall problems with three words.  Mood was euthymic.  Affect was bright.  He has no suicidal or homicidal/violence risks.  Perceptions were normal.  Thought process logical.  Thought content normal.  Disassociation none.  Sleep:  He is having some insomnia.  Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:,  He has a strong support system in his mother, grandmother, and mother's significant other, Richard.  He has good health.  He has shown gain from past treatment.  He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.
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DESCRIPTION: Psychiatric evaluation for ADHD, combined type.

The evaluation addresses several key issues in the patient's life, including the management of ADHD with medication that is causing side effects like insomnia and decreased appetite, behavioral concerns, family dynamics, and potential underlying mental health diagnoses. These factors affect the child's well-being, school performance, and family relationships. There are also hints of more serious issues such as thoughts of the 'S' word, which suggests suicidal ideation, although it doesn't seem to be actively present. While the situation requires careful medical management and monitoring, it doesn't appear to be immediately life-threatening or severely acute, reducing the stakes from the highest levels.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Consult - 1

HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, "December, November, September, October, June, July, August, September," but recognizes this was not right and then said, "March, April, May."  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.
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DESCRIPTION: Bipolar disorder, apparently stable on medications.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.

psychiatry / psychology, organic brain syndrom, substance abuse, bipolar disorder, mental, abuse,

The situation involves a 53-year-old woman with serious physical and mental health conditions, including severe aortic stenosis, bipolar disorder, and a history of substance abuse. She is refusing recommended cardiac surgery, which could significantly impact her health and possibly her life expectancy. Although her mental condition is stable and she is considered capable of making her own medical decisions, the decision to refuse surgery for a condition like aortic stenosis can lead to severe health consequences, making this a high-stakes situation. The collaboration needed among her care providers and the potential for significant health outcomes contributes to this being a high-stakes situation.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Paranoia

IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia "they want to hurt me.",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.
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DESCRIPTION: A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.

The situation involves a psychiatric patient with a history of schizophrenia experiencing acute symptoms due to noncompliance with medication. The patient's behavior led to legal consequences (arrest and jail) and the need for involuntary detention, highlighting the risk of harm to self or others if untreated. The patient's poor insight into his condition and the identified severe level of impairment (Axis IV: Severe) elevate this scenario to a high-stakes level, as its mismanagement could lead to significant harm or deterioration in the patient's condition.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych H&P - 2

HISTORY OF PRESENT ILLNESS:,  The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to recent medication adjustments.  The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.  In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  She was admitted voluntarily to the inpatient unit and medications were not restarted for her.  On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she "trust him."  The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter.  She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  The patient also complains that her daughter is "trying to tell me what medications to take."  The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:,  Per chart.  The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then.  It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1.  Seroquel 100 mg, 1 p.o. b.i.d.,2.  Risperdal 1 mg tab, 1 p.o. t.i.d.,3.  Actos 30 mg, 1 p.o. daily.,4.  Lipitor 10 mg, 1 p.o. at bedtime.,5.  Gabapentin 100 mg, 1 p.o. b.i.d.,6.  Glimepiride 2 mg, 1 p.o. b.i.d.,7.  Levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:,  Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:,  The patient is from Brooklyn, New York and moved to Houston approximately one year ago.  She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  She has been married once, but her spouse left her when her three children were young.  Her children are ages 47, 49, and 51.  She had one year of college, and she currently is retired after working in New York public schools for 20 or more years.  She reports that her spouse was physically abusive to her.  She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM:  ,GENERAL:  The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR:  The patient is singing loudly and joking with interviewers.  She is pleasant, but non-cooperative with interview.,SPEECH:  Increased volume, rate, and tone.  Normal in flexion and articulation.  MOTOR:  Agitated.,MOOD:  Okay.,AFFECT:  Elevated and congruent.,THOUGHT PROCESSES:  Tangential and logical at times.,THOUGHT CONTENTS:  Denies suicidal or homicidal ideation.  Denies auditory or visual hallucination.  Positive grandiose delusions and positive paranoid delusions.,INSIGHT:  Poor to fair.,JUDGMENT:  Impaired.  The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:,  Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6.  Acetaminophen level 3.3 and salicylate level less than 0.14.  WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL:  Alert and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT:  Normocephalic and atraumatic.  PERRLA.  EOMI.  MMM.  OP clear.,NECK:  Supple.  No LAD, no JVD, and no bruits.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.  S1 and S2 heard.  No murmurs, rubs, or gallops.,ABDOMEN:  Obese, soft, nontender, and nondistended.  Positive bowel sounds x4.,EXTREMITIES:  No cyanosis, clubbing, or edema.,ASSESSMENT:,  This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa.  The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I:  Schizoaffective disorder.,AXIS II:  Deferred.,AXIS III:  Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV:  Family strife and recent relocation.,AXIS V:  GAF equals 25.,PLAN:
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DESCRIPTION: Psychiatric History and Physical - Patient with schizoaffective disorder.

The situation involves a 69-year-old female patient with schizoaffective disorder experiencing significant psychiatric symptoms after a medication change, alongside other physical health conditions. The presence of manic symptoms, hallucinations, and poor insight poses a risk of harm to herself or others, though she has denied active suicidal or homicidal ideation. These factors, combined with the patient's inability to adequately care for herself and impaired judgment, make this a high-stakes scenario that necessitates immediate psychiatric intervention to stabilize her condition. The high Global Assessment of Functioning (GAF) score indicates severe impairment in functioning.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Schizophrenia

IDENTIFYING DATA:,  The patient is a 45-year-old white male.  He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission.  He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused.  He believes that he has been arrested and is in jail.  Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone.  His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  His partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home.  He reports that the patient has been eating regularly with no recent weight loss.  He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine.  He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  The patient was last enrolled in an outpatient mental health treatment in mid 2009.  He dropped out of care about six months ago when he moved with his partner.  His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  The patient is fairly vague on his history of AIDS related conditions, but does identify the following:  Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner.  He is unemployed.  Details of his educational and occupational history are not currently known.  His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  The patient reports smoking marijuana a few times in his life, but not recently.  Denies other illicit substance use.,LEGAL HISTORY:  ,Unknown.,GENETIC PSYCHIATRIC HISTORY:,  Also unknown.,MENTAL STATUS EXAM:,Attitude:  The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  His appearance is cachectic.  The patient is poorly groomed.,Psychomotor:  There is no psychomotor agitation or retardation.  No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect:  His affect is fairly detached.,Mood:  Describes his mood is "okay.",Speech:  His speech is normal rate and volume.  Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process:  His thought processes are markedly tangential.,Thought content:  The patient is fairly scattered.  He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  Paranoid delusions are elicited.,Homicidal/Suicidal Ideation:  He denies suicidal or homicidal ideation.  Denies previous suicide attempts.,Cognitive Assessment:  Cognitively, he is alert and oriented to person and year only.  His memory is intact to names of his Madison Clinic providers.,Insight/Judgment:  His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses.  His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets:  His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations:  His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION:  ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I:  Schizophrenia by history.  Rule out AIDS-induced psychosis.  Rule out AIDS-related cognitive disorder.,AXIS II:  Deferred.,AXIS III:  AIDS (stable by his report).  Anemia.,AXIS IV:  Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V:  Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers.  The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis.  With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past.  I anticipate titrating further for effect during the course of his admission.
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DESCRIPTION: A 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.

This case involves a patient with a history of schizophrenia and AIDS, who has recently exhibited disorganized and assaultive behavior. The patient is currently on a 72-hour involuntary hold due to grave disability. Given the complexity of managing both mental health and HIV-related conditions, and the patient's poor compliance with treatment, the situation is high-stakes. The patient’s partner reports increased paranoia, threats of harm, and impulsive behavior, heightening the risk. Medical intervention is necessary to manage both schizophrenia and HIV/AIDS-related health issues. Non-compliance and potential safety risks to the partner amplify the stakes.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Dementia

REASON FOR CONSULT,:  Dementia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions.  Symptoms started in June of 2006, when the patient complained of vision problems and disorientation.  The patient was seen wearing clothes inside out along with other unusual behaviors.  In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense.  The patient sought treatment from an ophthalmologist.  We did not find any abnormality in the Behavior Center in Tyler, Texas.  The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses.  The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college.  She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety.  Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006.  Sleeping patterns and the amount is unknown.  Appetite is okay.,PAST PSYCHIATRIC HISTORY:,  The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor.  She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work.  No current medications.  Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY:  ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother.  Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs.  The patient completed school, up to two years in college and worked as accounting tech for eight years.  Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel.  Decreased motor activity, but did blink her eyes often, but arrhythmically.  Poor eye contact.  Speech illogic.  Concentration was not able to be assessed.  Mood is unknown.  Flat and constricted affect.  Thought content, thought process and perception could not be assessed.  Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I:  Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II:  Deferred.,AXIS III:  Deferred.,AXIS IV:  Deferred.,AXIS V:  1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history.  There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate.  The patient presented with headaches, vision forms, and disorientation in June 2006.  She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests.  Thank you very much for the consultation.
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DESCRIPTION: Psychiatric Consultation of patient with dementia.

psychiatry / psychology, reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches,

The situation involves a patient with rapidly progressing early onset dementia, which is quite serious given the patient's age (33 years old). The condition has led to significant impairment in daily functioning, requiring assistance for activities of daily living (ADLs). The symptoms include disorientation, loss of vision, and ataxia, indicating a potential neurological disorder. The high stakes are due to the potential underlying causes of dementia at such a young age, which could include serious medical conditions that need prompt identification and management. Additionally, there is difficulty in diagnosing the exact cause due to the patient's inability to communicate effectively and lack of a comprehensive medical history. Immediate attention and further medical testing are required to prevent further deterioration and provide effective treatment.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Bipolar Affective Disorder

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.
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DESCRIPTION: A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.

The situation involves a patient with a psychiatric condition that has become severe enough to require hospitalization. The patient was noncompliant with outpatient treatment, presenting severe symptoms like mood lability, grandiose delusions, and a recent police incident indicating an acute episode. The stakes are high due to the risk of harm to self or others, potential legal complications, and the psychiatric nature of the issue which requires careful management and stabilization using medications.


Medical Specialty: Psychiatry / Psychology
Sample Name: Neuropsychological Evaluation - 4

REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory."  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined."  It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging."  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
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DESCRIPTION: The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

This situation involves a 58-year-old woman undergoing a neuropsychological re-evaluation after being dismissed from her position as a nurse due to possible early dementia. The stakes are high because the outcome of the evaluation could significantly impact her career, mental health, and future livelihood. A diagnosis could also influence her ability to perform daily activities safely and make important life decisions. Additionally, it may affect her decision to apply for disability retirement, further impacting her financial stability. Therefore, it involves significant consequences affecting various facets of her life.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Anxiety

REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  "I felt anxious yesterday.",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes."  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.
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DESCRIPTION: Psychiatric Consultation of patient with anxiety.

The situation involves a psychiatric consultation for a patient with pre-existing serious medical conditions, including metastatic breast cancer and anxiety with recent panic attacks. While the patient's immediate life is not in direct danger from the anxiety itself, her complex medical history makes effective management crucial for her overall well-being. Additionally, the presence of multiple health complications and potential medication interactions elevate the stakes beyond a routine consult. Therefore, while it's not life-threatening at the moment, the situation requires careful attention.