General Directions: making a mock psych evaluation on a patient….

General Directions: making a mock psych evaluation on a patient.
Describe in words everything. All diagnoses should be its own and not recommended for all. That is: the diagnoses made for this patient, along with a full set of differential diagnoses (if applicable). Adding any necessary citations along with reference.
Fill in the following: Identifying Information: Name Referred by: Address: Date of birth: Phone: Insurance: Other Identifying Information: Should state age, gender, sexual orientation, marital/social status, culture, religion, any other special identifying info. Chief Complaint: This is a quote (if possible) about why the patient is coming in for care today History of Present Illness • Reason that the patient is presenting for evaluation: • Psychiatric review of systems, 1 including anxiety symptoms and panic attacks • Past or current sleep abnormalities, including sleep apnea • Impulsivity Psychiatric History • Past and current psychiatric diagnoses (For diagnoses, give the DSM numeric as well as a narrative description) • Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide • Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts) • Prior suicidal ideas, suicide plans, and suicide attempts, including attempts that were aborted or interrupted as well as the details of each attempt (e.g., context, method, damage, potential lethality, intent) • Prior intentional self-injury in which there was no suicide intent • History of psychiatric hospitalization and emergency department visits for psychiatric issues • Past psychiatric treatments (type, duration, and, where applicable, doses) • Response to past psychiatric treatments • Adherence to past and current pharmacological and nonpharmacological psychiatric treatments Substance Use History • Use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements • Current or recent substance use disorder or change in use of alcohol or other substances Medical History • Allergies or drug sensitivities • All medications the patient is currently or recently taking and the side effects of these medications (i.e., both prescribed and nonprescribed medications, herbal and nutritional supplements, and vitamins) • Whether or not the patient has an ongoing relationship with a primary care health professional • Past or current medical illnesses and related hospitalizations • Relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments • Past or current neurological or neurocognitive disorders or symptoms* • Physical trauma, including head injuries • Sexual and reproductive history • Cardiopulmonary status • Past or current endocrinological disease • Past or current infectious disease, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme disease • Past or current symptoms or conditions associated with significant pain and discomfort Review of Systems • Psychiatric (if not already included with history of present illness) • Constitutional symptoms (e.g., fever, weight loss) • Eves • Ears, nose, mouth, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Endocrine • Hematological/lymphatic • Allergic/immunological Family History • History of suicidal behaviors in biological relatives (for patients with current suicidal ideas) • History of violent behaviors in biological relatives (for patients with current aggressive ideas • Other relevant family medical or psychiatric history Developmental History • Course of pregnancy and delivery • Were milestones reached at appropriate times Personal and Social History • Presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational or interpersonal/relationship problems; lack of social support: painful, disfiguring, or terminal medical illness) • Review of the patient’s trauma history • Exposure to violence or aggressive behavior, including combat exposure or childhood abuse • Legal or disciplinary consequences of past aggressive behaviors • Cultural factors related to the patient’s social environment • Personal/cultural beliefs and cultural explanations of psychiatric illness • Patient’s need for an interpreter Adaptive History: What stresses has the patient overcome in the past? How was it done? What does the patient consider to be was the best period of their life? What does the patient describe as their personal strengths? Current medications: List all medications for physical and psychiatric conditions, including prescribed, complementary, over-the-counter; who, where prescribed, how long taken. Use generic names for all medications, stating dose, route, and timing of dosage. Examination, Including Mental Status Examination • General appearance and nutritional status • Height, weight, and body mass index (BMI) • Vital signs • Skin, including any stigmata of trauma, self-injurv, or drug use • Coordination and gait • Involuntary movements or abnormalities of motor tone • Sight and hearing • Speech, including fluency and articulation • Mood, level of anxiety, thought content and process, and perception and cognition • Hopelessness • Current suicidal ideas, suicide plans, and suicide intent, including active or passive thoughts of suicide or death • If current suicidal ideas are present, assess • Patient’s intended course of action if current symptoms worsen • Access to suicide methods including firearms • Patient’s possible motivations for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations) • Reasons for living (e.g., sense of responsibility to children or others, religious beliefs) • Quality and strength of the therapeutic alliance • Current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide • If current aggressive ideas are present, assess • Specific individuals or groups toward whom homicidal or aggressive ideas or behaviors have been directed in the past or at present • Impulsivity, including anger management issues • Access to firearms Impression and Plan • Documentation of an estimate of the patient’s suicide risk, including factors influencing risk • Documentation of the rationale for treatment selection, including discussion of the specific factors that influenced the treatment choice • Considerations for differential diagnosis. • Asking the patient about treatment-related preferences • An explanation to the patient of the following: the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment • Collaboration between the clinician and the patient about decisions pertinent to treatment • Quantitative measures of symptoms, level of functioning, and quality of life • Documentation of an estimated risk of aggressive behavior (including homicide), including factors influencing risk • Documentation of the rationale for clinical tests • Medications: List all medications planned now as a full sig (include # dispensed, refills), treatment rationale, and any future treatment considerations. • Diagnostic Testing: List any diagnostic and laboratory testing that is plan to order or feel are necessary with a brief rationale of why. Remember, every test that was order should have a rationale of why. • Referrals: List all necessary referrals for additional care or assessments, physical and psychiatric. • Follow-up appointment: State when to plan to see this patient for follow-up and why chose this follow-up interval.

Similar Posts

Leave a Reply

Your email address will not be published. Required fields are marked *