Seen by DEPT. OF PSYCHIATRY, Dr.
INFORMANT:
REFERRED BY:
DIAGNOSED CASE OF:
CHIEF COMPLAINT:
INTER-CURRENT HISTORY:
Psychiatric review of systems is negative for depression, anxiety, psychosis, mania, repetitive behaviors, cognitive symptoms, substance use, personality changes
PAST HISTORY:
REVIEW OF SYSTEMS:
As above in Intercurrent history. Other pertinent constitutional symptoms, HEENT symptoms, cardiac symptoms, respiratory symptoms, gastrointestinal symptoms reviewed and negative
ALLERGIES AND MEDICATIONS:
EXAMINATION FINDINGS:
. Height cm Weight Kg BMI no Pallor | no Cyanosis | no Clubbing | no Lymphadenopathy | no Edema | no Malnutrition | no Dehydration Temperature Normal | Pulse rate /min, regular Respiratory rate /min Blood pressure Right Upper Limb mmHg | Left Upper Limb mmHg LMP if female pt Systemic examination findings: RS: AEBE, no rales, no ronchi CVS: s1,s2 present, no murmur AS: pa soft, no guarding/rigidity, no organomegaly CNS: no focal abnormalities
MSE:
Appearance:
alert and oriented to time, place and person
OBTUNDED
DISORIENTED
HYPERALERT
-
,
well kempt
POORLY KEMPT
appropriately dressed
INAPPROPRIATELY DRESSED
appropriately groomed
INAPPROPRIATELY GROOMED
DISHEVELED
-
,
normal posture
SLUMPED
RIGID
TENSE
-
.
Behavior:
calm
RESTLESS
AGITATED
RETARDED
PECULIAR
IMPULSIVE
-
,
interactive
WITHDRAWN
-
,
eye contact good
eye contact AVOIDANT
eye contact INTENSE
eye contact FLEETING
-
,
No EPSE
EPSE PRESENT
-
,
No abnormal involuntary movements
ABNORMAL INVOLUNTARY MOVEMENTS PRESENT
-
.
Attitude:
cooperative
HOSTILE
OVER FRIENDLY
SECRETIVE
EVASIVE
SUSPICIOUS
APATHETIC
EASILY DISTRACTED
FOCUSED
DEFENSIVE
DEMANDING
SEDUCTIVE
-
.
Speech:
spontaneous
NON-SPONTANEOUS
MUTISM
-
,
N reaction time
INCR REACTION TIME
DECR REACTION TIME
VARIABLE
-
,
normal rate
SLOW
POVERTY
PAUCITY
RAPID
OVERTALKATIVE
PRESSURE
-
,
normal volume
LOUD
SOFT
WHISPHER
MONOTONE
-
,
clear rhythm
SLURRED
HESITANT
APHASIC
-
.
Mood reported as:
, inferred as-
euthymic
NOT REPORTED
ANXIOUS
DEPRESSED
DYSPHORIC
IRRITABLE
ELEVATED
EXPANSIVE
ELATED
EUPHORIC
ANGRY
HOSTILE
INDIFFERENT
DETACHED
ANIMATED
-
Affect: quality:
euthymic
ANXIOUS
DEPRESSED
DYSPHORIC
IRRITABLE
ELEVATED
EXPANSIVE
ELATED
EUPHORIC
ANGRY
HOSTILE
INDIFFERENT
DETACHED
ANIMATED
-
,
range normal
BROAD
RESTRICTED
-
,
intensity normal
EXPANSIVE
BLUNTED
FLAT
LABILE
-
,
congruent
INCONGRUENT
-
.
Thought form:
coherent
INCOHERENT
CANNOT BE ASSESSED
NOT ENOUGH SAMPLE
-
,
logical and goal directed
-
CIRCUMSTANTIAL
TANGENTIAL
LOOSENING
FLIGHTS OF IDEAS
.
-
NEOLOGISM
BLOCKING
VERBAL PERSEVERATION
.
Thought content:
no delusion on current evaluation
DELUSION PRESENT
CANNOT BE ASSESSED
-
,
no active suicidal ideations at present
SUICIDAL IDEATIONS PRESENT
DEATH WISHES PRESENT
CANNOT BE ASSESSED
-
.
Perception:
no hallucination on current evaluation
HALLUCINATION
CANNOT BE ASSESSED
-
.
Insight:
present
PARTIAL
POOR
MOSTLY BLAMES OTHERS
DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS
CANNOT BE ASSESSED
-
.
Judgment:
intact
IMPAIRED
CANNOT BE ASSESSED
-
.
Cognition:
Clinically intact
ABNORMALITIES PRESENT
PENDING
CANNOT BE ASSESSED
-
.
normal attention, concentration, intact ability to recall recent and remote information, normal abstraction
ASSESSMENT/PLAN:
pt counseled refer omit add increase continue x follow up after
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