Case Presentation Order
Terms
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- Case Presentation Order
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Identifying Data
HPI
ROS
Past Psychiatric History
PMH
Family Psychiatric History
Past Social History
MSE
Working Diagnosis
Differential Diagnosis
Formulation
Workup
Treatment
Prognosis - Past Psychiatric History
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Diagnosis
Somatic Treatments
Past Treatments
Hospitalizations
Previous SI
Previous HI
Alcohol and Drug History
What has worked best - PMH
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Medical Problems
Medications
Allergies
Seizures
Head Injuries - Social History
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Developmental History
Educational Level
Current Family
Employment and Disability
Military History
Legal History
Abuse History - Case Presentation Differential Diagnosis
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Organic Etiologies
Psychosis
Anxiety
Affective
Substance
Somatoform
ADHD
TD
BIQ/MR - Organic Etiology Differential Diagnosis
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Medication Interactions (from OTC, withdrawal, herbals, or illicit drugs)
HIV and ARC
Encephalopathy (from Ca, Na, Mg, renal, or LFTs)
MS
Seizures
Autoimmune and Connective Tissue Diseases
Endocrine (thyroid or pancreas) - GAF
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90-100 – never symptoms
80-90 – no symptoms
70-80 – expected symptoms
60-70 – mild symptoms
50-60 – moderate symptoms
40-50 – serious symptoms
30-40 – severe impairments in multiple areas / reality testing impairments
20-30 – behavior influenced by reality testing impairments
10-20 – danger of harm; self-care compromised; gross impairments
1-10 – persistent danger; hygiene care non-existent - Formulation Elements
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Introduction
Strengths
Liabilities - Biological Formulation Introduction
- Anatomical, structural, and molecular substrates of disease and the effect on the patient’s biological functioning
- Biological Formulation Strengths
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Physical conditioning
Nutritional status
Stable medical problems - Biological Functioning Liabilities
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Genetic predisposition
Medical conditions
Drug effects (both prescription and illicit)
Early life trauma and kindling - Psychological Formulation Introduction
- Treatment of the effects of psychodynamic factors, motivation, and personality on the experience of and reaction to illness
- Psychological Formulation Strengths
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Intelligence
Willingness to accept help
Religion - Psychological Formulation Liabilities
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Low self-esteem
Impulsive behaviors
Losses
Drives
Narcissistic injuries
Defense mechanisms
Cognitive distortions - Social Formulation Introduction
- Examines cultural, environmental, and family influences on the expression of and experience of illness
- Social Formulation Strengths
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Skilled
Employed
Educated
Financially solvent
Needed by someone - Social Formulation Liabilities
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Stresses (occupational, partner, etc)
Lacking support network - Case Presentation’s Workup Plan
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Safety (be dramatic)
Review of Medical Records (with the patient’s permission)
Ancillary Data
Labs (“my usual practice is to shotgun, but in this case I am specifically looking for…â€)
Serial Examinations and Interviews (“It goes without saying that I would interview for longer and schedule further interviews)
Imaging Studies - Elements of the Treatment Plan
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Identification of the Goals of Treatment (both short- and long-term)
Psychoeducation
Biological
Psychological
Social - Short-Term Treatment Goals
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Physical safety of all involved in the care of the patient
Engagement in treatment which will lead to compliance
Alleviation of primary symptoms - Long-Term Treatment Goals
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Development of autonomy
Responsibility awareness
Foster and further insight
Social skills training - Elements of Psychoeducation
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Signs and symptoms of illness
Meaning of mental illness
Mental health resources (especially emergency psychiatric resources)
Relapse prevention - Goals of Biological Treatment
- Rapid alleviation of symptoms
- Elements of Biological Treatments
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Somatic treatments
Light therapy - Goals of Psychological Treatments
- Foster autonomy, insight, and responsibility awareness
- Psychodynamic Psychotherapy
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Believes current behavior, emotions, capacities for functioning, and patterns of relationships are deeply influenced by one’s experience throughout life
“The past shapes the present through known and unknown factorsâ€
Treatment takes place through verbal interaction between patient and therapist in an effort to elucidate unconscious past forces that affect current emotions and behavior
Paced between one to five sessions per week - Interpersonal Psychotherapy
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Focuses on the social role and interpersonal interactions in the patient’s past and current life experiences
Does not address internal conflict or defense mechanisms
Helps to build current capacity to function by a focus on one or two problem areas and strategies to build ways of dealing with current and future problems
Generally used as a short-term treatment model for depressed patients - CBT
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“What you think influences what you feelâ€
Seeks to identify the negative and faulty automatic thoughts and transform them to more realistic/rational thoughts
- gather evidence of validity
- refute assumptions
Requires an action plan for change
- homework
- desensitization
- increasing pleasurable activities - Goals of Social Treatments
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Manipulate the environment to assist the patient in the alleviation of symptoms
Answers the question of “Who will support them after they leave the office?†- Elements of Social Treatments
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Environmental manipulation (partial, ward, outpatient)
Work/school limitations
Psychoeducation for significant others
OT for work/rest/play balance and life skills learning