Psychiatry

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<title>Psychiatry / Psychology-Psych Consult - Schizophrenia (Medical Trans
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<H1> <b>Sample Type / Medical Specialty: </b> Psychiatry / Psychology<br
>
<b>Sample Name:</b> Psych Consult - Schizophrenia </H1>
<b> Description: </b> A 45-year-old white male with a history of schizop
hrenia and AIDS. He was admitted for disorganized and assaultive behaviors whil
e off all medications for the last six months.<br>
(Medical Transcription Sample Report)<br>
<hr>
<B>IDENTIFYING DATA:</B> The patient is a 45-year-old white male. He i

s unemployed, presumably on disability and lives with his partner.<br><br><B>CHI
EF COMPLAINT: </B> "I'm in jail because I was wrongly arrested." The p
atient is admitted on a 72-hour Involuntary Treatment Act for grave disability.<
br><br><B>HISTORY OF PRESENT ILLNESS: </B> The patient has minimal insight into
the circumstances that resulted in this admission. He reports being diagnosed w
ith AIDS and schizophrenia for some time, but states he believes that he has mai
ntained 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 h
is 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.<br><br>On the interview, the patient is still disorganized and confu
sed. He believes that he has been arrested and is in jail. Reports a history o
f mental health treatment, but denies benefiting from this in the past and does
not think that it is currently necessary.<br><br>I was able to contact his partn
er by telephone. His partner reports the patient is paranoid and has bizarre be
havior at baseline over the time that he has known him for the last 16 years, wi
th occasional episodes of symptomatic worsening, from which he spontaneously rec
overs. His partner estimates the patient spends about 20% of the year in episod
es of worse symptoms. His partner states that in the last one to two months, th
e patient has become worse than he has ever seen him with increased paranoia abo
ve the baseline and he states the patient has been barricading himself in his ho
use and unplugging all electrical appliances for unclear reasons. He also repor
ts the patient has been sleeping less and estimates his average duration to be t
hree 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 hi
s 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 longe
r feels that he is safe having him at home. He reports that the patient has bee
n eating regularly with no recent weight loss. He states that the patient is ob
served responding to internal stimuli, occasionally at baseline, but this has go
tten worse in the last few months. His partner was unaware of any obvious medic
al changes in the last one to two months coinciding with onset of recent symptom
atic worsening. He reports of the patient's longstanding poor compliance with t
reatment of his mental health or age-related conditions and attributes this to t
he patient's dislike of taking medicine. He also reports that the patient has e
xpressed the belief in the past that he does not suffer from either condition.<b
r><br><B>PAST PSYCHIATRIC HISTORY: </B> The patient's partner reports that the p
atient 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 psychiat
ric 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 drop
ped out of care about six months ago when he moved with his partner. His partne
r reports the patient was most recently prescribed Seroquel, which, though the p
atient denied benefiting from, his partner felt was "useful, but not dosed
high enough." Past medication trials that the patient reports include Haldo
l and lithium, neither of which he found to be particularly helpful.<br><br><B>M
EDICAL HISTORY: </B> The patient reports being diagnosed with HIV and AIDS in 19
94 and believes this was secondary to unprotected sexual contact in the years pr
ior 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 wi
th 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: Thr
ush, skin lesions, and lung infections; additional details of these problems are
not currently known.<br><br><B>CURRENT MEDICATIONS: </B> None.<br><br><B>ALLERG
IES:</B> No known drug allergies.<br><br><B>SOCIAL AND DEVELOPMENTAL HISTORY: <
/B> The patient lives with his partner. He is unemployed. Details of his educa
tional and occupational history are not currently known. His source of finances
is also unknown, though social security disability is presumed.<br><br><B>SUBST
ANCE AND ALCOHOL HISTORY: </B> The patient smoked one to two packs per day for m
ost of the last year, but has increased this to two to three packs per day in th
e last month. His partner reports that the patient consumed alcohol occasionall
y, 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 subst
ance use.<br><br><B>LEGAL HISTORY: </B>Unknown.<br><br><B>GENETIC PSYCHIATRIC H
ISTORY:</B> Also unknown.<br><br><B>MENTAL STATUS EXAM:</B><br>Attitude: The p
atient demonstrates only variable cooperation with interview, requires frequent
redirection to respond to questions. His appearance is cachectic. The patient
is poorly groomed.<br>Psychomotor: There is no psychomotor agitation or retarda
tion. No other observed extrapyramidal symptoms or tardive dyskinesia.<br>Affec
t: His affect is fairly detached.<br>Mood: Describes his mood is "okay.&q
uot;<br>Speech: His speech is normal rate and volume. Tone, his volume was dec
reased initially, but this improved during the course of the interview.<br>Thoug
ht Process: His thought processes are markedly tangential.<br>Thought content:
The patient is fairly scattered. He will provide history with frequent redirec
tion, but he does not appear to stay on one topic for any length of time. He de
nies currently auditory or visual hallucinations, though his partner says that t
his is a feature present at baseline. Paranoid delusions are elicited.<br>Homic
idal/Suicidal Ideation: He denies suicidal or homicidal ideation. Denies previ
ous suicide attempts.<br>Cognitive Assessment: Cognitively, he is alert and ori
ented to person and year only. His memory is intact to names of his Madison Cli
nic providers.<br>Insight/Judgment: His insight is absent as evidenced by his r
epeated questioning of the validity of his AIDS and mental health diagnoses. Hi
s judgment is poor as evidenced by his longstanding pattern of minimal engagemen
t in treatment of his mental health and physical health conditions.<br>Assets:
His assets include his housing and his history of supportive relationship with h
is partner over many years.<br>Limitations: His limitations include his AIDS an
d his history of poor compliance with treatment.<br><br><B>FORMULATION: </B>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 medicati
ons 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.<br><br><B>DIAGNOSES:</B><br>AXIS I:
Schizophrenia by history. Rule out AIDS-induced psychosis. Rule out AIDS-rela
ted cognitive disorder.<br>AXIS II: Deferred.<br>AXIS III: AIDS (stable by his
report). Anemia.<br>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.<br>AXIS V: Global Assessment Functioning is
currently 15.<br><br><B>PLAN: </B> I will attempt to increase the database, will
specifically request records from the last mental health providers. The Intern
al 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 a
t a dose of 100 mg at bedtime, given the patient's partner report of partial, bu
t response to this agent in the past. I anticipate titrating further for effect
during the course of his admission.
<br><Br>
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<B>Keywords: </B>
psychiatry / psychology, 72-hour involuntary treatment act, schizophreni
a, cognitive disorde, psychiatric history, mental health, aids, axis, behaviors,
mental,
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