Case presentation submission and treatment recommendations

Description

Initial Psychiatric Diagnostic Assessment

Initials:

Age:

Sex:

Marital Status:

Language:

Reason for Visit:

Allergies: (Include medication/food, adverse reaction and severity)

Chief Complaint: (patient concerns)

History of Presenting Illness:

a. Context: (Describe the story of what is going on with the patient; Describe chronic problem(s); Describe new problem(s); Describe what exacerbates the problem; Describe what led to current status… off medications, stress, progression of illness, substance abuse, past history trauma, etc.).

b. Location: (Describe the symptoms the patient is experiencing, such as, but not limited to: mood swings; psychosis; paranoia; hallucinations; anxiety; depression; panic attacks; PTSD; cognition problems, etc.).

c. Duration: {(Length of current/past episode(s); How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time?}.

d. Severity/Character: (mild, moderate, severe); (How bothersome is this problem? Does it interfere with your daily activities? If so, explain in detail; Does it keep you up at night?) {Try to have patient objectively rate the problem (Ask patient to rate symptom from 1 to 10 with 10); If it affects their activity level, determine to what degree this occurs.}

e. Timing: {Describe onset of symptoms- (i.e. 5 days ago; 1 month ago; 8 years ago, but worsened over the past 3 weeks; etc.); Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change?}

f. Associated Symptoms: {Here you list all the symptoms in detail (describe the story in more detail). (Describe the symptoms the patient is experiencing, such as, but not limited to: mood swings (describe the mood swings- depressed, then angry, then manic, etc.); Psychosis- specify type, such as paranoia (describe the paranoia); Hallucinations (describe type of hallucination; are these hallucinations command in nature? Non-command in nature? When do the hallucinations occur? If auditory hallucinations, are they male or female? Are they positive or negative voices? Provide an example by adding what the patient says the voices say; and so on….}

g. Modifying Factors: (Here you can list social factors and/or medical factors that may interfere or complicate treatment… homeless, death of spouse, lost job, cancer, starting college, abuse, jail, DV, stress, divorce, etc.).

Past Psychiatric History:

Past Diagnosis: (list age of dx if known)

Past Suicide Attempts: (year or age, date if known, method, note if potentially lethal)

Past Violence:

Previous Admits: (when, where, why, brief list)

Outpatient Services:

Past Medication Trials:

Family Hx of Psychiatric Disorders:

Family Hx of Completed Suicide:

Substance Abuse History:

Nicotine: (explain type; quantity; route; etc)

ETOH: (explain type; quantity)

Caffeine: (explain form; amount; time of day used)

Illicit: (explain type; quantity; route; etc)

Prescription: (name drug; explain type; quantity; route; etc)

Substance Abuse Tx Hx: (explain type; quantity; route; etc)

Psychosocial/Family History:

Relationship Status:

Children:

Support System:

Housing:

Income:

Education: (include if achieved developmental milestones on time)

Legal:

Abuse/Trauma:

Spirituality:

Military Service:

Cultural Concerns:

Medical History:

Family Medical Hx:

Patient Medical/Surgical History:

Patient Current Medical Issues:

Current Scheduled Medications

(include name; dosage; route; frequency; reason for use, any side effects)

(medications that are continued or changed are to be listed in the treatment plan)

1.

2.

PRN Meds

1.

2.

Testing/Consult results: (Psychological testing, Speech evaluation, OT/PT)

PSYCHIATRIC ASSESSMENT

Sleep Schedule/Hygiene (include if snores):

Appetite:

Attending to Hygiene:

EPS:

MENTAL STATUS EXAM

(yes/no, WNL, Appropriate, Normal, intact are not appropriate for describing mental status items. Describe the behavior or observed presentation.

Appearance:

Motor Activity:

Attitude:

Speech:

Affect:

Mood:

Thought Processes:

Thought content:

Suicidal ideation:

Homicidal ideation:

Self-Injury:

Cognition (estimate of intellect):

Orientation:

Memory:

Insight:

Judgement:

Psychomotor Activity:

Fund of Knowledge:

Cognitive Function Abilities:

Attention span-

Concentration-

Abstract thinking-

Concrete thinking-

Metaphors-

Standardized Assessment:

(ie. Beck Depression Inventory, Young Manie Rating Scale, PHQ-9)

Type:

Score:

Interpretation of Results:

Diagnoses (List in order of priority)-

Include DSM 5 code, identify data/symptoms of the assessment that support this diagnosis, and if full or partial criteria is met

1.

2.

Differential diagnosis (minimum of 2)

Include DSM 5 code, what data/symptoms need further follow up to rule in or rule out these diagnoses, what additional questions would you ask, what additional assessments would you want

1.

2.

Plan: (minimum of 3 psychosocial interventions)

Comprehensive plan, focus on addressing each diagnosis, what psychosocial education would your client find beneficial, if therapy, what kind and what type of therapy(theory), include frequency. If needed address housing, financial, family and employment concerns. Any lab work or additional testing you may want to recommend. Include brief rationale for each

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Why this patient was chosen (a paragraph explaining why this client was selected, why did you personally choose this client)

At least 2 questions regarding clinical decision making not related to medications, and not related other aspects of the student response rubric the presenter would like other students to address.