Name:
CC:
HPI:
Age:
current sx, depression/mania/psychosis screen, safety, compliance, stressors, EtOH/Drugs (inc w/d)
Past Psych Hx: (including substance abuse):
Inpt/Outpatient, Med Trials, Suicide/Violence
DDX: Put the case together with a good 1 liner
Family Hx: (mental illness, substance abuse,
suicide)
mentioning the lead diagnosis. Then give supporting
positives and negatives from the interview and MSE to
support your lead diagnosis and other diagnoses on your
differential. Mention that you would like more info
(collateral/labs) to make an accurate diagnosis. Remember
substance induced d/o and psych sx secondary to medical
problems.
Social Hx: (education, income/employment/
disability, living situation, marriage/partner/kids,
legal, hx trauma/abuse)
PMH: (remember to ask about TBI)
Allergies:
Meds:
MSE: appearance, behavior, speech, mood, affect,
thought process, content, memory/concentration,
insight and judgment
Axis I. Psychiatric d/o including Substance abuse
Axis II. Personality d/o and developmental disorders
Axis III. Medical Problems
Plan:
1. Admit/Discharge Patient
2. Safety Level
3. Medical wk up (labs/imaging)
4. Collateral information
5. Medications to start/continue
6. Think about dispo issues (all pts need a safe d/c
plan including appropriate outpatient care and a safe
place to live). This may include shelter, group home
placement, case manager, psychiatrist +/psychotherapist, substance abuse treatment,
psychosocial rehab (day program/clubhouse).