This clinical write-up encompasses a detailed examination of a patient presenting with depression and anxiety. It includes an extensive history of present illness, past psychiatric history, family and personal history, and substance abuse history. The mental status exam evaluates appearance, behavior, speech, mood, perception, thought content, cognition, insight, and judgment. The document concludes with a diagnosis according to DSM-5 criteria, current medications, and a treatment plan, providing a holistic view of the patient’s mental health status and therapeutic approach.
Student Name:
Write Up #
Typhon Case #
Semester/Year:
Course:
| 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) |
Use this template of this table for each medication. Try to use your own words. For example, how would you explain this information to them or their family?
| 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 |
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
Read moreYour email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
Read moreBy sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
Read more