ID:
, Date:
, Name:
, Age:
, Gender:
Male
Female
Other
SEEN BY:
DEPT. OF PSYCHIATRY, Dr.
INFORMANT:
REFERRED BY:
DIAGNOSED CASE OF:
Presenting symptoms / Main symptoms:
mandatory for PMJAY
History of Present illness:
mandatory for PMJAY
Psychiatric review of systems is negative for depression, anxiety, psychosis, mania, repetitive behaviors, cognitive symptoms, substance use, personality changes
ROS:
NAD
as below
NOTE:
GENERAL:
no
fever
-
,
chills
-
,
night sweats
-
,
anorexia
-
,
wt loss
-
,
fatigue
-
,
malaise
-
.
SKIN:
no
rashes
-
,
lesions
-
,
itching
-
,
dryness
-
,
sweating
-
,
hair loss
-
.
EYES:
no
glasses
-
,
vision problems
-
,
eye discomfort
-
,
eye discharge
-
,
photophobia
-
.
ENT:
no
earache
-
,
ear discharge
-
,
vertigo
-
,
hearing problems
-
,
tinnitus
-
.
no
nose congestion
-
,
nose bleeds
-
.
no
sore throat
-
,
hoarsness
-
,
dysphagia
-
,
odynophagia
-
,
neck lumps
-
.
BREAST:
no
lump
-
,
pain
-
,
discharge
-
.
RS:
no
cough
-
,
sputum
-
,
hemoptysis
-
,
dyspnea
-
,
wheezing
-
.
CVS:
no
chest pain
-
,
palpitation
-
,
dyspnea
-
,
orthopnea
-
,
PND
-
,
syncope
-
,
edema
-
.
GI:
no
abdo pain
-
,
nausea
-
,
vomiting
-
,
diarrhea
-
,
constipation
-
,
bowel habit changes
-
,
jaundice
-
,
hemetemesis
-
,
blood in stool
-
,
tarry stool
-
.
GU:
no
painful urination
-
,
GU discharge
-
,
hematuria
-
,
flank pain
-
,
frequent urination
-
,
nocturia
-
,
incontinence
-
,
hesitancy
-
,
difficulty urinating
-
.
MALE GENITAL:
no
testicular pain
-
,
testicular lump
-
,
genital pain
-
,
genital lesion
-
.
FEMALE GENITAL:
no
amenorrhea
-
,
dysmenorrhea
-
,
menorrhagia
-
,
vaginal bleeding
-
,
pelvic pain
-
,
genital pain
-
,
genital lesion
-
.
MUSCULOSKELETAL:
no
back pain
-
,
joint pain
-
,
joint swelling
-
,
muscle pain
-
,
muscle weakness
-
,
stiffness
-
.
PSYCH:
NEURO:
no
headache
-
,
head injury
-
,
weakness
-
,
numbness
-
,
tingling
-
,
tremor
-
,
seizure
-
,
syncope
-
,
dizziness
-
,
cognitive sx
-
.
HEMATOLOGICAL:
no
easy bruising
-
,
easy bleeding
-
,
lymphadenopathy
-
.
ENDO:
no
cold intolerance
-
,
heat intolerance
-
,
sweating
-
,
excessive thirst
-
,
excessive hunger
-
,
excessive urine
-
,
weight changes
-
.
History of Past illness:
mandatory for PMJAY
FAMILY H/O:
SOCIAL H/O:
MEDICATIONS:
ALLERGIES:
Examination Findings:
mandatory for PMJAY
. 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
Mental Status Examination:
mandatory for PMJAY
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
Investigation Details:
mandatory for PMJAY
Investigations:
complete profile done at SKH listed first
Cognitive Tests, Complete Haemogram, Liver Function Test, Renal Function Test, Serum Electrolytes, Electrocardiogram, CT or MRI Brain, Electroencephalogram, Thyroid Function Test, VDRL, HIV Test, Vitamin B12 levels, Lipid Profile
or choose from tests below
Cognitive test
, Complete Hemogram
, Liver function test
, Renal Function test
, Serum Electrolytes
, Electrocardiogram ECG
, CT Brain
, MRI Brain
, Electroencephalogram EEG
, Thyroid function test
, VDRL
, HIV
, Vitamin B12 level
, Folate level
, Lipid profile
, Homocystiene level
Patient Diagnosed by:
Doctor Name:
Patient type:
Diagnosis:
mandatory for PMJAY
Primary diagnosis: Diagnosis description:
Plan of treatment:
mandatory for PMJAY
Category Name: XXIII MENTAL DISORDERS PACKAGES
Package Type:
routine ward
1. F00-F09 Organic, including symptomatic, mental disorders
2. F10-F19 Mental and Behavioral disorders due to psychoactive substance use
3. F20-F29 Schizophrenia, schizotypal and delusional disorders
4. F30-F39 Mood (affective) disorders
5. F40-F48 Neurotic, stress-related and somatoform disorders
6. F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors
7. F70-F79 Mental retardation
HDU
8. F00-F09 Organic, including symptomatic, mental disorders
9. F10-F19 Mental and Behavioral disorders due to psychoactive substance use
10. F20-F29 Schizophrenia, schizotypal and delusional disorders
11. F30-F39 Mood (affective) disorders
12. F40-F48 Neurotic, stress-related and somatoform disorders
13. F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors
14. F70–79 Mental Retardation
15. Pre-Electro Convulsive Therapy (ECT) and Pre-rTranscranial Magnetic Stimulation (TMS)Package
16. Electro Convulsive Therapy (ECT)
Units doctor name: Dr. Himanshu Sharma, Dr. Anusha Prabhakaran, Dr. Jagdish Varma, Dr. Nisheet Patel
following sections for routine use
LABS:
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