The psychiatric case note

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The psychiatric case note. For CCR meeting 27 November 2007. Chris Gale. Development. Medicine & Neurology: history and examination. Phenomenology  detailed clinical description. Psychotherapy  developmental, formulation. UK (Maudsley)  manualised traditional file. - PowerPoint PPT Presentation

Text of The psychiatric case note

  • The psychiatric case note.For CCR meeting27 November 2007.

    Chris Gale

  • Development.Medicine & Neurology: history and examination.Phenomenology detailed clinical description.Psychotherapy developmental, formulation.UK (Maudsley) manualised traditional file.Problem orientated medical notes.Computerisation and consumer input.

  • Traditional (Maudsley) assessment.ReferralHistory Presenting complaint.Past HistoryFamily HistoryDevelopmental HistorySocial historyMental State examination.Physical examination.FormulationDiagnosis Plan.

  • Referral/ Triage.Who referred?What are concerns?Is there an issue of risk?Is there an issue of urgency?Who is the proposed patient?How and when can they be seen?

  • History.What are the compliants?Patient.Family / whanauWider community.When, where, what is associated, exacerbating, relieving, attribution of symptoms, how long.Consequences:DisabilitySuffering.System review.

  • System review.CardiovascularRespiratoryGenito-urinaryNeurologicalEndocrine Psychiatric.

  • Psychiatric systems review.SleepEnergyAppetiteWeight gain or lossDelusions & hallucinations.Self-harm.Tedium vitae, neglect, self-harm (cutting, burning)Suicide ideation, plans, attempts.

  • Past history.MedicalSurgicalAllergiesCurrent medicationsSubstancesPastCurrent (Cut down Abstinent Guilt Eye opener)Forensic.

  • Psychiatric Past History.Previous episodes.WhenWhat were symptoms then.TreatmentMedications.Psychotherapies.Attribution recovery | continuation symptoms.CollateralOld notesFamily

  • Family history.MedicalPsychiatric.Relatives experiences:Service (esp. adverse)Treatment (successful and adverse).Substances.Suicide.

  • Developmental I: the family players.Geno-gram.Age, job.Support, conflict.Isolation or support

  • Developmental II: Life history.InfancyEarly childhood.Primary schoolSecondary schoolTraining / University.WorkRelationships.

  • Developmental III: personality.Usual (premorbid) personality.Percieved strengths & weaknesses.Hobbies, interests.Methods of coping.LossStressCurrent situation.What supports & strengths currently accessible.

  • Socail.Living.Who withRent or own.Food, heating.Financial Legal Current charges.Care childrenFinancial (IRD, debt, bankruptcy).Substance abuse (in twice so will ask once)

  • [Physical examination.]Nutrition (Height, weight. BMI)Cardiorespiratory, (pulse, BP)CirculationNeurological(abdominal and g-u very rarely, usually referred).

  • Mental State Examination.BOTAMIBehaviorOrientationTalk and ThoughtAffectMood Insight and Judgement.

  • Behaviour.Three As.AppearanceActivity.Specific comment extra-pyridoxal side-effects EPS.Comment if responding non-apparent stimuli (NAS) i.e.. Hallucinating.AttitudeRapport.

  • Orientation.Aware time, place, person.Level of consciousness.Bedside tests.MMSEExtensions (idiosyncratic list of tests).Clock face.Similarities and differences.Approximations.Verbal fluency.Fist-side-palm.Repeat assessment at another time if concerned organic (delirium workup first).

  • [Delirium workup]Rule out correctable causes.Detailed physical examination and investigations as appropriate. Usual include:CBC, CXR, MSU.LFTs [VDRL, Hep C, HIV].Na, K, Urea, CreatinineGlucoseECGCT head (any history trauma, any neurological signs).

  • TalkRate & FlowNormal, StaccatoLaconic. Over inclusiveMuteProsody

  • ThoughtFormOrganisedIncludes circumlocutory (does not lose goal)Disorganised (loss of goal)Loosening of associations word salad.NB flight of ideas manic moodContent.Describe phenomena & themes.

  • AffectRangeMobility.Restricted Labileaffect is weather, mood is climate.

  • MoodRich vocabulary mood states.AngrySadAnxiousHappyTechnical terms.Hypomanic never involves psychotic symptoms.Dysphoria implies does not currently meet criteria depression.

  • InsightComprehendInformation you provide & other sources.Cognitively processImpaired by defence mechanisms.CommunicateChoices to you.

  • [Defense mechanisms I]High adaptiveAnticipation, affiliation, altruism, humour, self-assertion, self-observation, sublimation, suppressionCompromise formationDisplacement, dissociation, intellectualisation, isolation of affect, reaction formation, repression, undoing.

  • [Defense mech II]Image distortion, minorDevaluation, idealising, omnipotenceDisavowalDenial, projection, rationalisation.Image distortion, majorAutistic fantasy, projective identification, splitting (self image, others)

  • [Defense mech III]ActionActing out, apathetic withdrawal, help-rejection complaining, passive regression.Defensive dysregulationDelusional projection, psychotic denial, psychotic distortion.

  • JudgementAbility to understand consequences actions.ANDAbility to take responsibility for actions.

  • Formulation (psychiatric)Summary sentence presentation.Predisposing factorsPrecipitating factorsPerpetuating factors.[Choice of model flows from problem]

  • DiagnosisDSM AxesPsychiatric syndromePersonalityMedical conditionSocial stressorsLevel of function.

  • Plan.Place of careRisk management (suicide, self harm, harm others)Use inpatient, respite, MHA.BiomedicalInvestigations.MedicationsECT, light therapy.PsychologicalSocialRisk management (money, child care etc).Functional assessment & rehabilitation.

  • Assessment Write up.Traditionally 5-6 sheets A4, or 2-4 pages typed.Plan followed opinion (driven by doctor).Risk loss previous knowledge.

  • Traditional note or letter.Process of interview.Content of interviewAssessmentInterventionsOngoing plan.

  • Psychotherapy process note.DynamicNarrative.Defences and TransferenceInterpretations.Structured.Plan / protocol session.Adherence / homeworkProcess of session.HomeworkPlan next session.

  • Psychopharm progress note.Process interview.Symptoms including side-effectsLevel of functionFocused mental state.Relevant investigations.Medication changes / current medications.

  • Current recordsBased on Problem orientated medical record Good medical record.Case management modelNegotiated with patient / client.Redundant recording: risk of contradiction.Risk Prevention PlanAdvance directiveManagement plan.Risk being unread.

  • [Problem orientated medical record]Invented in 1970s.Database (initial assessment & investigations.Problem list.Plan.

  • [Problem orientated progress notes.]List of active problems.For each problem SOAPSubjectiveObjective (MSE findings, outcome scales etc).AssessPlan

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