Psychiatric Evaluation Comprehensive Skeleton Name: DOB: Age: Informant: Gender: Ethnicity: Primary Language:
Reliability:
Chief Compliant: History of Present Illness:
COLDSTART Protective Factors Who/what helps you with your life? Include support systems, personality, community, family, and spirituality/religion; Coping skills Goals, Areas for improvement Sleep Patterns, Appetite, Weight Change
Educational History/Employment History current functioning Safety SI (serious thoughts of death and dying)/HI (plan, method, intent); physical/sexual abuse; PTSD Current Medications/Past medications Do/did they work?? How? Stressors Medical History allergies; asthma; GERD; Head Injuries; Seizures; immunizations; past surgeries Psychiatric History: Developmental History: Social History drug use/ETOH use; peer relationships and peer history/sibling/family relationships; cultural issues; sexually active Abuse History Legal history Substance Abuse- History: Substance, How much, How often, Trx received Strengths Likeable qualities Friendly Expresses feelings, Motivated for treatment, Assertive, Caregiver available/supportive Self-worth Optimistic Socially active Intelligent Family History Psych SA/ETOH, pertinent medical, family social history, current functioning Family History Medical Current MSE Appearance, General behavior, Motor behavior(movement disorders), LOC, Attitude toward examiner, Speech, Mood, Affect, Thought processes/Reality testing, Thought content, Cognition(attentiveness, language, memory, abstract reasoning, constructional ability) Insight, Judgment, Concentration/Attentiveness
Differential Dx: Axis I, Axis II, Axis III Axis IV Severity of Psychosocial Stressors (mild, mod, severe) Problems with: Primary Support Group Educational/Occupational stress Legal Problems Access to Health Care Chaotic family environment Peer Pressure/Bullying Economic/Financial stress Health problems Social Environment Home stress Housing Other
Axis V Current GAF
Potential GAF over next year
>70Mild or no symptoms/impairment 50-70Moderate symptoms/impairment 30-50Severe symptoms/impairment < 30Hospitalization likely needed
Formulation
Recommendations: Provide education regarding diagnosis and treatment to patient and family; Order medications (or Medication deferred today pending further assessment) Individual, Group & Family therapy; Provide medication information and counseling(risk vs. benefits, uses/indications, side effect profile, and potential adverse drug events); Signs of new or worsening suicidality potential in medication ordered; Educational services at appropriate cognitive level; Labs (Routine: FBS, Lipids, Glucose, CBC, Free T3, Free T4, BMP)/Special: vitamin D, vitaminB12, Lithium, Valproate Acid, ect.); EKG; Monitor weight, BP,P BMI regularly, at least quarterly; Collaborate with PCP as necessary Follow-up COLDSTART (OLDCARTS for Mental Health) C What do you believe is happening in your life that is affecting your level of functioning? What made you have to come here? O Onset When did this start? Has this ever happened to you before? L Location Where does this occur (home, school, playground)? Is disturbance thought, mood, behaviors? D Duration How long does this usually last? S Severity How much of a problem is this in your life? T Time When does this occur (time of day, time of year, frequency of occurrences) A Associated signs and symptoms Symptoms present but not tied in with main cluster of symptoms.
R Relieving/Aggravating Modifying factors T Treatment What types of things have been tried (meds, hospitalizations, therapies). Effectiveness?
Depression assessment: S Sleep I Interest (Enjoyment) G Guilt (helpless/hopeless/worthless) E Energy C Concentration A Appetite P Psychomotor S Suicide
Any problems with depression should include assessment of mania (DIGFAST) D-Distractible I-Irritability G-Grandiosity F-Flight of ideas A-Activity (increase) S-Sleep (decrease) T-Talkative
MENTAL STATUS EXAM Appearance - overall impression, posture, clothes, grooming, health, apparent age, angry/afraid General Behavior - mannerisms, gestures, combative, rigid, twitching, psychomotor retardation Attitude toward examiner - cooperative, hostile, defensive, seductive, evasive, ingratiating State of consciousness - lethargic, alert, hyper alert Attention span - concentration, attend, digit recall Orientation - person, place, time, situation Psychomotor Activty calm, increased, reduced, agitated, abnormal movements Mood - overall emotional state (sad, happy, depressed, elated, anxious, irritable) Affect - current emotional state (full, labile, restricted, flat, inappropriate) Speech - rate (incr, pressured, slow), tone (soft, angry) volume, articulation, language (aphasia) Form of thought - circumstantial, flight ideas, evasiveness, reality testing,loosening associations, perseverance, blocking Content of thought - preoccupations, obsessions, phobias, rituals, delusions, depersonalization Perceptions - misperceptions, illusions, hallucinations, Judgment - describes clients ability to predict the consequences of her/his behavior, to make sensible decisions, to recognize her/his contribution to her/his problem. Memory - immediate (digit span), recent (three objects at 5 minutes), remote (days to years)
Insight - do they realize they are ill, denial, defensive reaction to feedback, reacts appropriately to fedback Intellectual Functioning- fund of knowledge, calculations(serial 3s or 7s), abstraction (proverbs, similarities) Impulse control fair, poor, sexual, aggressive, self-injurious actions Suicidal/Self-injurious thoughts, feelings, intent, ideas, plan Homicidal thoughts, feelings, intent, ideas, plan
