Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 15

Description: Complaint of mood swings and tearfulness.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.

FAMILY HISTORY: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.

ALLERGIES: She is allergic to Sulfa.

CURRENT MEDICATIONS: Recently finished Minocin and Duraphen II DM.

PHYSICAL EXAMINATION:
General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.
Skin: Without rash.
Eyes: PERRLA. Conjunctivae are clear.
Neck: Supple with adenopathy or thyromegaly.
Lungs: Clear.
Heart: Regular rate and rhythm without murmur.

ASSESSMENT:
1. Postsurgical menopause.
2. Mood swings.

PLAN: I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well.

Keywords: consult - history and phy., tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are 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 been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples