Extension for Community Healthcare Outcomes
Integrated Addictions & Psychiatry Clinic
Patient Case Presentation
Date:_____________ Presenter: ________________ ECHO id: _______________ DOB:_______________
Gender: M___ F____ New Case:__________ Follow-up: ______________
PLEASE STATE YOUR QUESTION FOR THE ECHO IAP NETWORK:
⃝ Help with diagnosis
⃝ Help with medications
⃝ Help with non-medication treatment
Symptoms
Depression:
Mania:
Anxiety:
Psychosis:
Insomnia/hypersomnia
Distractibility
Trauma
Delusions
Diminished Interest
Indiscretion
(dangerous
activities)
Hypervigilance
Hallucinations
Increased Startle
Auditory/Visual/Tactile
Avoidance
Disorganized behavior
Worthlessness/Guilt
Loss of energy
Diminished
concentration
Grandiosity
Flight of ideas
Significant weight loss
Activity Increase
Psychomotor
agitation/retardation
decreased need
for Sleep
Suicidal
ideation/thoughts of
death
Talkativeness
Negative Cognitions
Excessive Worry
Panic Attacks
Obsessions
Compulsions
DURATION:
DURATION:
Other:
Screening/Assessment Tool Scores (list any that apply):
PHQ-9:
Level 2
Depression:
GAD-7:
Level 2 Anxiety:
Severity of
Posttraumatic
Stress Symptoms:
Severity Measure
for Social Anxiety
Disorder:
Severity Measure
for Panic
Disorder:
Level 2 Mania:
Extension for Community Healthcare Outcomes
Level 2 repetitive
Thoughts and
Behaviors:
Clinician-Rated
Dimensions of
Psychosis Symptom
Severity:
Level 2 Sleep
Disturbance:
Other:
Proposed Diagnoses:
1.
2.
3.
4.
Psych HX:
Hospital admission: (When/indication):
Meds tried in past:
Antidepressants
Antipsychotics
Anxiolytics
Mood
Stabilizers
Non-pharmacological Interventions Tried:
TRIED?
HELPFUL?
Community Resources
Y/N
Y/N
Community Reinforcement
Approach
Y/N
Y/N
Seeking Safety
Y/N
Y/N
Motivational Interviewing
Y/N
Y/N
Behavioral Activation
Y/N
Y/N
Relaxation Strategies
Y/N
Y/N
Interoceptive Exposure
Treatment
Y/N
Y/N
Anger Management
Y/N
Y/N
Mindfullness
Y/N
Y/N
Other:
Y/N
Y/N
History of:
Suicide attempt: Y/N
If yes, date of last attempt:
Non-suicidal Self-Injurious Behaviors: Y/N
If yes, date of last NSSIBs:
Others
Extension for Community Healthcare Outcomes
Homicide attempt: Y/N
Current Medications: (Attach a med list
if possible)
Medical Comorbidities:
1.
2.
2.
3.
3.
4.
1.
4.
PDMP checked: Yes__________ No ___________ Pertinent Findings: __________________________________________
Substance Use History:
Quantity
Frequency
Last Use
Caffeine
Nicotine
Alcohol
Methamphetamine
MDMA
Heroin
Opiates
Hallucinogens
Inhalants
Benzodiazepines
OTHER:
History of substance use disorder treatment:
Substance Abuse counseling: Past: Y/N Present: Y/N
Inpatient Substance Abuse Treatment: Y/N
12-steps/Mutual Support Groups: Past: Y/N
Present: Y/N
LABS
TSH:
Drug levels:
UDM:
Hep C:
CBC:
HIV:
CMP:
LFTs:
Other:
Family Psychiatric History:
1.
Route
Extension for Community Healthcare Outcomes
2.
Partnered:
3.
Legal involvement:
4.
Housing: homeless/secure/transient
Access to guns: Y/N
Social History:
Exercise: none/scant/regularly
Education level:
Hobbies:
History of abuse/neglect/violence:
Race/ethnicity:
Employed:
Sexual Orientation:
Goals for treatment:
1.
2.
3.
4.
Proposed Treatment Plan:
1.
2.
3.
4.