Clinical write , Patient male with 18 years old with DX : ADH

What brought you here today…? (Put this in quotes.)

“

Depression symptoms: Can you describe your depression symptoms? What makes the depression better, what makes the depression worse? Does the depression, come and go?

Anxiety: Does the anxiety come and go or is there all the time? Does anything make the anxiety worse or better? Do you go into panic? If so, how often and how long does it usually last?

Mood swings: Do your moods go up and down? If so, can you tell me more about a typical mood swing?

Anger/irritability: Do you get angry more than you should? How do you act when you get angry?

Attention and focus: Do you have trouble concentrating or staying on track?

Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself?

Hallucinations: Do you ever hear or see anything that other people may not hear and/or see?

Paranoia: Do you feel like people are talking about your or following you?

Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? Once you get to sleep, do you stay asleep all night or are you up and down throughout the night?

At what age did the mood symptoms start?

Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis?

Where there any environmental factors that could have contributed to the moods? For example, divorce, death in the family, etc.

Any previous treatment and if so, what was it and did it work? List any previous psychiatric medications have been tried and why the medication was stopped.

Include parents, siblings, grandparents if applicable/known; pertinent mental health history.

Education, marital status, occupation, work history, and legal history

Do you currently or in the past used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used?

Do you currently or in the past had an issue with alcohol abuse? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past?

Do you currently smoke cigarettes or vape?

Do you smoke marijuana?

Medical problems

Previous surgeries

Appearance: Gait, posture, clothes, grooming

Behaviors: mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions

Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive

Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating

Orientation: “What is your full name?” “Where are we at (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?”

Rapport

Quantity descriptors: talkative, spontaneous, expansive, paucity, poverty.

Rate: fast, slow, normal, pressured

Volume (tone): loud, soft, monotone, weak, strong

Fluency and rhythm: slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic

Mood (how the person tells you they’re feeling): “How are you feeling?”

Affect (what you observe): appropriateness to situation, consistency with mood, congruency with thought content

· Fluctuations: labile, even, expansive

· Range: broad, restricted

· Intensity: blunted, flat, normal, hyper-energized

· Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

Congruency: congruent or not congruent mood?

Paranoia

Auditory hallucinations

Visual hallucinations

Suicidal

Homicidal

Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)

· Delusions are fixed, false beliefs.

· These are unshakable beliefs that are held despite evidence against it, and despite the fact that there is no logical support for it.

· Is there a delusional belief system that supports the delusion?

If not a delusion, then could it be an overvalued idea (an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. – the person is able to acknowledge the possibility that the belief is false)?

Ideas of Reference (IOR): everything one perceives in the world relates to one’s own destiny (e.g., thinking the computer or TV is sending messages or hints).

First rank symptoms: auditory hallucinations, thought withdrawal, insertion and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings or actions experienced as made or influenced by external agents

What is actually being said? Does the content contain delusions?

Are the thoughts ego-dystonic or ego-syntonic?

What is the logic, relevance, organization, flow, and coherence of thought in response to general questioning during the interview?

Descriptors: linear, goal-directed, circumstantial, tangential, loose associations, clang associations, incoherent, evasive, racing, blocking, perseveration, neologisms.

Cognitive testing

Education level

What is their understanding of the world around them and their illness?

Are they able to do reality-testing (i.e., are they able to see the situation as it really is)?

Are they help-seeking? Help-rejecting?

What have their actions been? Have they done anything to put themselves or other people at harm?

Are they behaving in a way that is motivated by perceptual disturbances or paranoia?

What is your confidence in their decision making?

Medical medications (list)

Psychiatric medications (list)

Brand/generic name

Dose at the time of visit

Starting dose

How does this medication work?

Major side effects

Is this medication FDA approved for why the person is using this medication?

Patient education

Medication class

Current diagnosis

DSM-5 symptom criteria for each diagnosis (write out
DSM-5 symptom criteria)

Did they display/state any symptoms that match the diagnosis?

ICD 10 Code

Billing Code

Medication changes made during visit

Clinical impression

Recommended therapy/support sources for person and the reason why

Next visit scheduled