Choose 2 psychiatric patients and complete below with each patient
Subjective:
Chief Complaint:
History of Presenting Illness (HPI):
Past Psychiatric History:
Past Medical History:
Social/Developmental History:
Allergies:
Objective:
Mental/Functional:
Mental Status Examination:
Appearance:
Orientation:
Speech/Language:
Mood:
Affect:
Thought Content:
Insight:
Judgement:
Suicidality & Homicidality:
Assessment:
DSM-V Diagnoses:
Risk Assessment:
Vital Signs:
Height/Weight/BMI:
Plan and Recommendation:
Supportive psychoeducation:
Safety Plan:
Medications:
Follow-up:
SAMPLE
SUBJECTIVE
Chief Complaint: “ I feel depressed and sad.”
History of Presenting Illness: Ashley and her mother presented for initial evaluation. She reported struggling with depression since September of 2018. She described her depression as sadness, irritability, lack of motivation and interest. She feels overwhelmed and easily agitated. She also feels anxious and panic attacks sometimes. She reported lack of appetite some times. Mother reported Ashley cries for no reason. She would tell mother that she cries for no reason. Mother got concerned about this. She then took her to the Doctor who referred her to the hospital. Ashley did well at school with report card of A’s, B’s, C’s. She also reported difficulties with attention and focus. She gets distracted easily. She struggles with completing class and home. Mother reported since she started 8th grade, Ashley has been struggling.
Past Psychiatric History: No hospitalization. She is not in therapy. She is has not been on medications. No drugs or alcohol use.
Medical History: No past medical history has been documented for this patient.
Psychiatric Family History: No family history of mental illness.
Social /Developmental History: Ashley lives with her parents and her siblings. Mother described her pregnancy as normal. She weighed about 6 pounds 6 ounces. Her developmental milestones were normal. No abuse or neglect. Ashley is going into the 8th grade in regular education.
Allergies: No known allergies
OBJECTIVE
Mental/Functional:
Normal
Mental Status Exam:
Appearance: Attire was casual; adequate hygiene and grooming
Orientation: Oriented to person, place, time, event/situation
Speech/Language: Clear; spontaneous, normal rate; normal prosody
Mood: “I feel sad and depressed”
Affect: congruent
Thought Content: No obsessions/compulsions; no evidence of perceptual disturbances
Insight: Good
Judgment: Good
Suicidality and Homicidality: Denies
ASSESSMENT
DSM-5 Diagnoses:
1) ADHD, predominantly combined type
2) Generalized anxiety disorder
3) MDD, RE, moderate
Risk Assessment: The patient denies SI/HI and/or behaviors, intent, and/or plan. Current protective and risk factors were reviewed, and the patient is not currently at clinically significant risk for suicide/homicide. The patient acknowledged understanding of emergency resources such as going to the ER or dialing 911 if experiencing suicidal/homicidal ideation.
Vitals:
Ht: 5’0”
Wt: 132lbs oz
BMI: 25.78
PLAN AND RECOMMENDATION:
1) Supportive psychoeducation completed
2) Safety plan discussed
3) Medications:
– No prescription today. Consider medications after completing the forms.
Complete Conner’s Scale provided for teachers and parents.
Complete baseline EKG
Overall treatment plan was discussed with the patient. Patient voiced understanding.
Continue to require outpatient treatment and medications.
Risks, benefits, side effects, and alternative treatments regarding prescribed medications were discussed with the patient/family. Patient expressed understanding and provided informed consent to be on aforementioned medications.
Rechecks with PCP for further evaluation and treatment of medical problems. Patient voiced understanding.
Patient was advised to immediately return to clinic, call 911, or go to the nearest ER for worsening symptoms, side effects, thoughts of harming others, or any concerns. Patient verbalized understanding.
Referrals: Psychotherapy encouraged
Next Follow-up: 4 weeks or sooner if needed
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