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Initial Diagnostic Evaluation
May 16, 2019
•
Mark Morgan
categories:
Psychiatry & Psychology
*Chief Complaint*
Date and Time of Service:
Provider Location: home
Patient Location: home
Informed consent: This is a telehealth visit with the patient located in their home. The Provider informed the patient of the benefits and risks of telehealth, including the risk that personal information could be exposed during a telehealth visits, or that technical problems and/or the type of health problem being treated could result in suboptimal transmission of information for medical decision making. Patient understands they have the right to discontinue or refuse treatment at any time, and request the same service in a face-to-face setting. Patient verbalized consent for this visit.
The following was discussed with the patient by office staff: The patient was informed that the visit will be documented in the patient’s medical record, same as with face-to-face visits. The Patient understands they have the right to verify the identity of their telehealth provider
Intended Modality: Telehealth
Modality of Service performed:
Successful video telehealth visit
Telephone visit due to video link being unavailable
Telephone visit due to patient declining video service
other
Total Time of Visit:
60 min
10 min
15 min
20 min
25 min
30 min
45 min
60 min
time
Greater than 50% of the visit was spent on counseling and education
Identifying Information:
Patient name
is a
age
-year-old,
ethnicity
,
single
married
partnered
cis-gender female
cis-gender male
transgender female
transgender male
gender non-binary individual
other gender
who
lives with their significant other
lives with their family
lives alone
is homeless
lives with their parents
lives with their children
lives with a roommate
lives in a grouphome
in
residing location
.
They are their own guardian
They have a DHS guardian
Their guardian is
guardian
.
speech input
Additional presentation information
History of Presenting Illness:
name
presents in this outpatient appointment
initially presented to the emergency department
alone
with family
with significant other
with DHHS worker
with case manager
by police
names
for evaluation and management of
due to reports of
presenting problem
.
The patient reports
The family reports
The Guardian reports
The case manager reports
Electronic records indicate
Police report indicates
a past history of
no history of mental health concerns until
no history of mental health concerns
speech input
Mental health history
.
depression
anxiety
sleep
mood
ptsd
adhd
autism
name
's depression is characterized as
little interest or pleasure in doing things
hopelessness
helplessness
sleeping too much
difficulty getting to sleep
difficulty staying asleep
feeling tired or having little energy
poor appetite
overeating
feelings of inadequacy
irritability
poor concentration
psychomotor retardation
psychomotor agitation
suicidal ideation
.
Depressive symptoms are present most of the day, nearly every day
Depressive symptoms are mostly present
, are exacerbated by
, are improved by
.
Depressive symptoms impact
social/work functioning by
speech input
.
speech input
Additional Depression information
name
's anxiety generally presents as
feeling nervous or on edge
worry
difficulty relaxing
feeling restless
difficulty getting to sleep
difficulty staying asleep
irritability
poor appetite
overeating
.
Anxiety is present
in the context of multiple different situations/events such as
primarily in social situations such as
speech input
.
Anxiety usually last for approximately
Anxiety is present most of the time on most days
, is brought on by
, is relieved by
.
speech input
Additional Anxiety information
Mood instability has been an issue since
.
Disordered mood can present as
euphoria
excessive energy
excessive self-confidence
insomnia
irritability
agitation
racing thoughts
impulsive behavior
risk taking behavior
paranoia
delusions of grandeur
auditory hallucinations
visual hallucinations
depression
apathy
hopelessness
helplessness
suicidal thoughts
no motivation
hypersomnia
.
Mood lability is exacerbated by
There are no identified precipitating factors to mood lability
speech input
.
speech input
additional information of mood lability
Per patient,
Per family,
Per record,
they have been
patient has been
diagnosed
undiagnosed
autism spectrum disorder
speech input
details of diagnosis/symptom timeframe
.
name
's symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including:
abnormal or failed back and forth conversation
failure to initiate or respond to social interactions
reduced sharing of interests/emotions
limited emotional affect
limited/incongruent nonverbal communication
difficulty with developing/maintaining/understanding relationships
difficulty sharing imaginative play
limited or absent interest in peers
. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including:
repetitive motor movements
repetitive speech
infexible adherence to routines
ritualized patterns of verbal or nonverbal behavior
significant difficulty with transitions
rigid thinking patterns
highly restricted and fixated interests
hyper-reactivity to sensory input
hyporeactivity to some sensory input
. Presentation is
without
with
intellectual impairment, and
without
with
language impairment.
speech input
name
has a pattern of
inattention and hyperactivity/impulsivity
inattention
hyperactivity/impulsivity
that interferes with functioning.
Inattention manifests as
poor attention to details or careless mistakes in work or activities
difficulty sustaining attention
not seeming to listen when spoken to directly
not following through on instructions or failing to finish tasks
having difficulty organizing tasks and activities
avoiding tasks that require sustained mental effort
frequently losing things necessary for tasks
often easily distracted by extraneous stimuli
forgetfulness in daily activities
At least 6 for ADHD
.
name
's hyperactivity/impulsivity presents as
frequent fidgeting or squirming
often leaving seat when remaining seated is expected
frequently restless
difficulty engaging in leisure activities quietly
often seeming to be on the go or difficult to keep up with
excessive talking
blurting out answers before a question has been completed
difficulty waiting for their turn
interrupting or intruding on others
six or more for ADHD
.
These symptoms have been present since
before 12yo
, and are recognized in multiple settings including
2 or more
.
speech input
Sleep is reported to be generally
poor
fair
good.
erratic
inconsistent
excessive
with difficulty initiating sleep and staying asleep due to
with difficulty initiating sleep due to
with difficulty maintaining sleep due to
speech input
. They estimate getting approximately
hours of
broken
solid
sleep per night.
Disturbed sleep has been an issue for
Disturbed sleep is a new issue within the last
speech input
.
There has been no workup for Sleep Apnea
There was a past workup for sleep apnea which indicated
speech input
.
Current attempts at improving sleep include
The patient is currently attempting no interventions to improve sleep
Current quality of sleep is dependent on
speech input
.
Past unsuccessful attempts at improving sleep include
There have been no past attempts at improving sleep
speech input
.
Sleep is reported to be generally good.
They deny any marked issues with depression.
They deny any significant issues with anxiety.
Current psychiatric medications include:
They are not currently taking any psychiatric medications
Patient is unable to recall current medications
Unable to cover current psychiatric medications with patient due to symptomatic presentation
speech input
.
Other medical medications include:
Other medical medications are noted below.
speech input
.
Medication list obtained from patient.
Medication list obtained from medical record.
Medication list obtained from patient's guardian.
Medication list confirmed with patient's pharmacy.
Medication list confirmed with patient's grouphome.
They are not currently receiving individual counseling/therapy
They are currently engaging in individual counseling with
speech input
.
They deny current suicidal ideation or thoughts of self harm
They report positive for
They deny suicidal ideation but state having thoughts of being better off dead
speech input
.
They are able to contract for safety.
They deny being able to contract for safety.
speech input
They deny having access to guns
They report positive for having guns in the home
speech input
.
Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide.
Hide Healthcare Provider Section
Current Healthcare Providers:
Primary Care:
speech input
none
Dental:
speech input
none
speech input
Other
Scales
Scales and Screening:
PHQ-9:
unable to assess
declined
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
GAD-7:
unable to assess
declined
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
MDQ:
negative
unable to assess
declined
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
HITS:
negative
unable to assess
declined
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
PC-PTSD:
negative
unable to assess
declined
1
2
3
4
AUDIT:
negative
unable to assess
declined
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
DAST-10:
negative
unable to assess
declined
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
SLUMS:
N/A
unable to assess
declined
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
PSYCHIATRIC HISTORY:
Previous psychiatric medication trials include but may not be limited to:
The patient has no history of taking psychiatric medications
We were unable to cover previous psychiatric medication trials due to symptomatic presentation
The patient is unable to recall past psychiatric medication trials
speech input
.
There is no history of psychiatric hospitalizations
They have been psychiatrically hospitalized
speech input
.
Previous psychiatric/counseling services includes
They have no history of psychiatric/counseling
History of psychotherapy/counseling was not addressed due to symptomatic presentation
speech input
.
They deny history of diagnosis/treatment for an eating disorder
They report positive for a history of diagnosis/treatment for an eating disorder including
Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation
History of diagnosis/treatment of an eating disorder was not assessed in this encounter
speech input
.
They have no history of thoughts of self-harm
History of thoughts of self harm include
speech input
.
They have no history of attempting to hurt themself
History of self-harm includes
Unable to obtain history of self-harm due to symptomatic presentation
speech input
.
They have no history of head injuries or traumatic brain injuries
They have a past history of traumatic brain injuries resulting from
They have an underlying cognitive impairment from
speech input
.
There is no history of trauma
They report having a history of trauma but did not want to elaborate
They report past traumatic experiences to include
Trauma history was not covered due to symptomatic presentation
speech input
.
They report positive for tobacco use consuming approximately
They report a past history of tobacco but quit approximately
They deny any tobacco use
speech input
.
They report positive for alcohol use consuming approximately
They report a history abuse quitting approximately
They deny any alcohol use
speech input
.
They deny a history of recreational substance use
They report utilizing cannabis approximately
They have a history of opiate use disorder
They report utilizing opiates recreationally in the form of
Substance use history was not covered due to symptomatic presentation
speech input
.
DEVELOPMENTAL HISTORY:
name
was born in
place of birth
to an intact family
to a family structure consisting of
speech input
.
There is no known issue with meeting expected developmental milestones
All developmental milestones were met with exception to
There were some notable issues with developmental milestones including
. Their primary language includes
English
language
and utilizes
written and verbal communication
primarily verbal communication
primarily textual communication and sign language
speech input
.
SOCIAL HISTORY:
name
identifies
having no one
significant other
extended family
children
friends
church members
speech input
as their social-support network. They have
0
1
2
3
4
5
6
7
speech input
children. Their level of education is
highschool
an undergraduate degree in
a graduate degree in
some highschool
some college
currently in grade school
currently in highschool
currently in college studying
currently in graduate school studying
speech input
. They are
currently on disability due to their mental health condition
currently on disability due to their medical condition
currently employed
currently retired from
speech input
. Financially they
have no immediate concerns
are burdened by healthcare costs
have concerns related to supporting their family
speech input
. Their source of income is primarily
disability
social security
unemployment
current employment
family support
retirement
speech input
. They have
no current housing concerns
a currently unstable housing situation related to
speech input
.
Spirituality was not addressed this visit
Spirituality is identified as
Christian
Catholic
Muslim
Jewish
Spiritual but not practicing
Athiest
Agnostic
speech input
.
Cultural considerations important to care include:
speech input
. Sexual orientation
is identified as
was not addressed this visit
heterosexual
homosexual
bisexual
pansexual
asexual
speech input
.
They have no military history
Military history includes
Military history was not addressed this visit
speech input
.
They have no current legal concerns
Legal concerns include
Legal concerns were not addressed due to symptomatic presentation
speech input
.
FAMILY PSYCHIATRIC HISTORY:
They deny knowledge of a family history of mental illness
Family history of mental health problems is positive for
Unable to cover family history of psychiatric issues due to symptomatic presentation
speech input
.
There is no known history of suicides or self-harm in the patient's family
Family history of suicides/self-harm includes
Unable to cover family history of suicides/self-harm due to symptomatic presentation
speech input
.
There is no known family history of substance use issues
Family history of substance use is positive for
Unable to cover family history of substance use issues due to symptomatic presentation
speech input
.
REVIEW OF SYSTEMS:
The patient identifies the following symptoms:
Pertinent System
irritability
mood instability
heightened anxiety
attention problems
troubled by hallucinations
fearfulness
nightmares
alcohol cravings
opiate cravings
speech input
other
Other systems:
Neurological -
Headaches
weakness
disturbed sleep
denied
speech input
other
GI -
Upset stomach
nausea
constipation
heatburn
denied
speech input
other
All other systems negative
MENTAL STATUS EXAM:
Patient presents as
alert and oriented to
disoriented to
person, place, and time
speech input
.
Recent and remote memory are intact
Recent memory is intact, although issues with remote memory include
Remote memory is intact, although issues with recent memory include
Issues with recent and remote memory are noted to be
speech input
additional information about memory
.
Attention span and concentration are adequate
Difficulty with attention span and concentration are evidenced as
speech input
. Their language skills are
adequate,
limited,
difficult to assess due to the degree of symptomatic presentation
and consistent with education
and inconsistent with education
speech input
. Their fund of knowledge is
appropriate for stated age and education level
inappropriate for stated age and education level
difficult to assess due to symptomatic presentation
speech input
.
They are capable of abstraction
They display difficulty with abstraction
Assessment of abstraction ability difficult due to symptomatic presentation
speech input
. They appear to be
their stated age
younger than their stated age
older than their stated age
speech input
. They are
well groomed
unkempt
,
appropriately dressed
inappropriately dressed
speech input
,
in their own clothes
in hospital clothes
speech input
, with
normal posture
slumped posture
rigid posture
speech input
. Their behavior presents as
calm
restless
agitated
irritable
anxious
impulsive
speech input
, and
interactive
inattentive
withdrawn
speech input
with good eye-contact
with intermittent eye-contact
with avoidant eye-contact
speech input
.
Their gait presents as
They are incapable of ambulating
normal
abnormal
unsteady
shuffling
spastic
speech input
.
Muscle strength and tone are
equal for all limbs with free range of motion
speech input
. Speech is
a regular rate and rhythm
rapid
slow
speech input
, spontaneous
, appears prepared
, fluid
, slurred
, monotone
, pressured
, laconic
, normal volume
, quiet
, loud
speech input
speech input
. Thought processing and content present as
adequate,
delayed,
logical,
illogical,
reality based
additional descriptors
disorganized
circumstantial
tangential
flight of ideas
loose association
perseveration
thought blocking
ideas of reference
grandiose
paranoid
persecutory
religious
somatic
self accusatory
speech input
.
No evidence of hallucinations or delusions
Hallucinations/delusions characterized as
speech input
.
No evidence of preoccupation with violence
They have a reoccupation with violence as evidenced by
speech input
.
They deny suicidal ideation
They report positive for suicidal ideation without intent
They report positive for suicidal ideation with intent
speech input
.
They deny homicidal ideation
They affirm homicidal ideation toward
speech input
. Their judgment concerning everyday activities is
good
fair
poor
impaired
speech input
. Their insight concerning their psychiatric condition is
good
fair
poor
impaired
speech input
.
Hide Risk Assessment Section
RISK ASSESSMENT:
The patient is at a
low
moderate
high
acute and
low
moderate
high
chronic risk of suicide based on
lack of current suicidal ideation
current suicidal ideation without a plan or intent
current suicidal ideation with a plan
other
treated psychiatric symptoms at this time. The patient has
no history of suicide attempts
a history of suicide attempts
a recent history of suicidal ideation
difficulty with supportive relationships
a minimal support system in the community
. They present as
future oriented
with plans for self-improvement
having a strong sense of personal responsibility
ambivalent about personal outcomes
pessimistic about personal outcomes
.
speech input
additional information about suicide risk factors
The patient is at a
low
moderate
high
acute and
low
moderate
high
chronic risk of violence based on
lack of current violent ideation
current violent ideation without a plan or intent
current violent ideation without a plan
and
well
moderately
poorly
treated psychiatric symptoms at this time. The patient's history is reported to include
no history of agitation and violence
a recent history of agitation and violence
difficulty with mood regulation
but has improved significantly with treatment
has made moderate improvement with treatment
has made minimal improvement with treatment
has made no improvement with treatment
.
speech input
additional information about violence risk factors
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