Please complete Assignment based on the first patient I presented in my SOAP note. I am attaching as a reference. You can add in more information as you seen fit to make the assignment. Please follow the professor format closely below. The assignment should include at least 4 References.
Psychiatric Evaluation (AKA Psychiatric History and Physical)
Format should be in the H & P format outlined below. Grading rubric is also below.
H & P FORMAT: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice. Information found below under headings can be used as prompts but are not meant to be all inclusive of information needed.)
IDENTIFYING INFORMATION: The patient is a (age, marital, ethnicity, gender) who presents today for a psychiatric eval (reason/referral). Sources of information for this evaluation include pt report, collateral info from.., available old records. The patient was/was not able to give an account of his/her activities/life events/symptoms in a chronological order.
HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).
Should use the OLDCARTS acronym when trying to elicit characteristics of symptoms.
Remember to include pertinent negatives.
HPI MUST contain validation of diagnoses. Include your pertinent review of systems (ROS) here. You do not need to do an exhaustive review, only what is pertinent to the patient’s CC. Frequent symptoms that are reviewed in a psych eval are constitutional, neurological. Remember that the ROS is SUBJECTIVE. This is not the place for assessment findings ie. Lungs clear, BS present all 4 quad, skin is clear, appears to be responding to internal stimuli, etc…
PAST PSYCHIATRIC HISTORY:
Be sure to include previous treatment, response to treatment, and explore the seriousness and context of self harm or suicide attempts. Ask about hospitalizations or partial hospitalizations. If they have been diagnosed with psychiatric illness before, ask what type of provider made the diagnosis and why. This helps you understand the patient’s insight and understanding.
PREVIOUS PSYCHIATRIC MEDICATIONS: Question carefully about length of trials, dose, why d/c
SUBSTANCE USE/ ADDICTIVE BEHAVIORS: If + is a higher risk for suicide. First use and circumstances surrounding use, consequences of use (social, legal, economic, relational, health), last use, pattern, CAGE- Cut down-Annoy-Guilt-Eyeopener. Detox/Rehab? How do they handle stress? How often is use, how much, what is the most you did in one day? Be wary of denial/minimization. Any withdrawal S&S? Ask specifically about classes of drugs , illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics, bath salts, designer drugs, and non controlled like gabapentin, Seroquel, or artane), nicotine, or caffeine (also comes in pill form) and route (“have you ever snorted anything? Injected anything? Taken pills that were not prescribed to you or taken your prescription other than as directed?” Routes include insufflation (snorting) IV, oral, sublingual, transdermal, anal, or vaginal).
Inquire about eating, spending, gaming, gambling patterns. May also begin to inquire about sexual habits.
FAMILY PSYCHIATRIC HISTORY:
Good response to meds? If yes, which ones?
Dx by psych or self diagnosed?
MEDICAL HISTORY: Head injury, seizures, EEG, CT scan, review of pertinent labs, Current Medical Problems, chronic illnesses (lupus, fibromyalgia, arthritis, parkinsons, thyroid issues, cardiac disease, HTN, diabetes, cancer) any meds that have caused s&s? New onset of illness that causes stress? Last period, pregnancy test? Eating disorders? Sexual history
History of Med Illness
Ability to work and love. (work=ability to structure daily activities, meet expectations, relate adequately to peers and supervisors, take on level of responsibility. Long term relationship=ability to attend to others needs, control impulses, make a commitment.)
Childhood/developmental history, family of origin, siblings, birth order, relational status, marital status-how long, children, housing situation, education, employment, abuse, religious/spiritual beliefs, legal(consider antisocial or substance abuse if extensive)
Born and raised where/by whom/siblings/relationship status
MENTAL STATUS EXAM: (OBJECTIVE).
Must be in narrative form.
Include all elements and be as descriptive as possible. Please refer to Kaplan and Sadock text, Ch. 5, pgs. 201-205 and the Carlat or Robinson texts.
Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters
Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.
Spontaneity or Latency
Qualities of Affect
Mood as defined by patient. Usually in quotation marks
T- Thought process
Flow and processing of thought. Examples:
Fight of ideas
T- Thought content
Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation
Psychotic ideation or perceptual disturbances. Examples:
Delusions or hallucinations
Ideas of reference
Significant themes related to diagnosis
C- Cognitive exam – consider educational attainment when interpreting results.
Memory (long and short term)
Fund of knowledge
PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)
This section will vary in scope dependent on the setting.
DIAGNOSTIC IMPRESSION WITH FORMULATION:
RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:
When providing treatment recommendations, be as holistic and comprehensive as possible. When describing rationales for these recommendations be as specific as possible. It is not sufficient to explain that a treatment is FDA indicated and then to outline the mechanism of action of the drug. Explain why you (or your preceptor) chose a particular drug or treatment in lieu of another. For instance, why escitalopram instead of citalopram or fluoxetine, or sertraline, etc…?
Remember to include all information that was actually done but also include, in italics, other or additional actions you would have taken or things you would have done differently.