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Psychiatry H & P

Identifying Information:

  • Age
  • Ethnic racial background
  • Marital status + number of years couple has been together
  • Home lived + number of years
  • School attended+ place worked-how many years

Chief complaint: “patient’s own words.”

HPI

  • 1st time pt ever saw a psychiatrist
  • Mention the top 5/6 things you want us to discuss today because the last thing I want to do is waste your time
  • 5 things that must be ruled out in psychiatry:
    • Mood (Depression, Mania, Anxiety)
    • Psychosis
    • Substance use
    • ± Suicidal Ideations (SI)àplan/intent?
    • ±Homicidal Ideation (HI)
    • Legal problem issues
    • Tobacco use
    • Major stressors
    • Side effects of meds

Past Psychiatry Hx:

  • How many times have you been hospitalized? (1st & last)-where, when, why?
  • How many meds are you taking?-previous medication trials
  • What meds has helped you the most?
  • History of suicide attempts.

Med Hx:

  • Allergies
  • Primary Care Physician
  • When was your last physical exam?

ROS:

  • HTN
  • DM
  • Heart
  • Liver
  • Kidney
  • Cholesterol
  • Thyroid
  • Neurological issuesàtics/motor/seizures/head trauma

Surgeries

Vaccinations up to date?

Med list and what they are for:

  • If on Lithium/Tegretol/Valproic acidàcheck levels
  • STDs
  • HIV-chronic medical condition

Family Hx

  • Ages of parents & siblings
  • Hx of psych, drug, or alcohol problems

Social hx

  • Please describe your childhood in one word-happy, ugly, terrible?
  • Hx of physical or sexual abuse
  • Years in school
  • Longest held job
  • Religion
  • Career goal in life

MSE

  • Appearance
  • Alertness
  • Eye contact
  • Speech
  • Mood
  • Affect
  • Thought process
  • Thought content
  • Cognition
    • concentration
    • calculation
    • intellect
    • judgment
    • insight
    • abstraction
    • memory

Psychodynamic formulations (i.e. understanding of the case)

  • discuss predisposing, precipitating, & perpetuating issues in a person’s life from a biopsychosocial, cultural, & spiritual perspective

Differential Diagnosis (5-7 potential):

Axis I-principal disorder

Axis II-Personality disorders, Mental retardation

Axis III-General medical issues

Axis IV-Psychosocial stressors

  • primary support (problem with wife)
  • social
  • environmental
  • educational
  • economic
  • access to health
  • legal

Axis V-GAF

GAF

  • 90-100: superior functioning
  • 80-90: above average
  • 70-80: good
  • 60-70: transient
  • 50-60:mild symptoms
  • 40-50: moderate symptoms
  • 30-40: serious symptoms
  • 20-30: some impairment in reality testing
  • 10-20: presence of hallucinations or delusions which influence behavior
  • 1-10:some/persistent danger of harm to self or others
  • **Note: check DSM IV for details

Treatment

  • Person in danger or not in danger
  • Patient appropriate for level of service-inpatient/partial hospitalization program/outpatient
  • General medical issues-consent for release of information to access general medical issues through medical progress notes and labs
  • Discuss risks and benefits of alternative treatment options including no treatment at all
  • Provide treatment recommendations from a biopsychosocial, cultural and spiritual perspective

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