DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation for medical clearance for electroconvulsive therapy.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old currently in intensive therapy unit with worsening depression for the last year. She currently denies any suicidal or homicidal ideation. However, she has requested medical clearance for ECT. The patient did receive ECT in the past and had good response with that. This new request for ECT has already been okayed by two psychiatrists and this only required medical clearance at this time. The patient’s last ECT was approximately 15 years ago.
PAST MEDICAL HISTORY: Significant for depression, which is now recurrent, and panic disorder.
PAST SURGICAL HISTORY: Bilateral tubal ligation and polypectomy of the uterus.
SOCIAL HISTORY: The patient denies smoking, drug or alcohol use.
ALLERGIES: Refer to chart.
HOME MEDICATIONS: Cymbalta, Klonopin, and Risperdal.
FAMILY HISTORY: Father had a coronary artery bypass graft.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6, pulse 62, blood pressure 106/66, and respiratory rate 18.
GENERAL: The patient is alert and oriented x3, in no acute distress, thin, well nourished and well hydrated.
HEENT: Normal oral mucosa.
LUNGS: Clear to auscultation bilaterally with good air movement.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft and nontender. Positive bowel sounds.
EXTREMITIES: Without edema. No erythema.
BACK: Straight. No deformities. No flank pain.
CURRENT MEDICATIONS: In the intensive therapy unit included Klonopin 0.5 mg every noon and 1 mg p.o. at bedtime, Cymbalta at 90 mg p.o. daily, mirtazapine 15 mg p.o. at bedtime, and Risperdal 2 mg p.o. at bedtime.
LABORATORY DATA: White count 4.6, H and H of 13.2 and 39.4, and platelets 270,000. Sodium 138, potassium 4.0, chloride 102, CO2 of 26, BUN 14, creatinine 0.8, and glucose 90. Alkaline phosphatase 38, ALT 15, and AST 24. Pregnancy test was negative. TSH 0.892. RPR is negative.
DIAGNOSTIC DATA: Chest x-ray was negative. Thoracolumbar spine x-ray showed no fracture, no subluxation with disk space preserved. EKG done three days ago showed normal sinus rhythm. No ST changes and normal segment.
ASSESSMENT AND PLAN: This is a (XX)-year-old female with recurrent major depressive disorder needing medical clearance for electroconvulsive therapy. At this point, electrocardiogram and exam is within normal limits. Thus, we will give an okay for electroconvulsive therapy from our medical standpoint, especially as she is a nonsmoker with no chronic medical issues of cardiac or diabetes and has a normal electrocardiogram rhythm strip. The patient is a good candidate, especially as she has had a good response with electroconvulsive therapy previously.
