Psychiatry
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[remark]MSE section start[/remark][checkbox name="mse" value="MENTAL STATUS EXAMINATION:"][conditional field="mse" condition="(mse).is('MENTAL STATUS EXAMINATION:')"]
Appearance: Patient is [select value="cooperative|WITHDRAWN|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"], [select value="alert,|LETHARGIC,|SLEEPY,|STUPUROUS,|COMATOSE,|"][select value=" and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"], [select value="dressed appropriately for age and season|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED appearance|-"], [select value="with normal posture|with SLUMPED posture|with RIGID posture|with TENSE posture|-"]. [select value="|Patient "][checkbox value="is OBESE|is OVERWEIGHT|is UNDERWEIGHT|is EMACIATED|appears OLDER THAN STATED AGE|appears YOUNGER THAN STATED AGE|has DYSMORPHIC features|is UNSHAVEN|has WOUNDS|has SCARS|has BLOOD STAINS|has BANDAGES|has TATTOOS|has worn JEWELLERY|has glasses|has dental braces|has missing LIMB|is REEKING OF SMELL OF ALCOHOL|emanates BODY ODOUR|has worn SOILED CLOTHES|is UNDRESSED|is UNDERDRESSED|is OVERDRESSED|is BIZARRELY DRESSED|has worn UNIFORM|was TEARFUL during interview"]. [textarea cols="20" rows="1"]
Behavior: Psychomotor activity appears [select value="normal|ABNORMAL|RESTLESS|AGITATED|RETARDED|HYPERACTIVE|PECULIAR|IMPULSIVE|CATATONIC|-"]. [select value="|Patient "][checkbox value="has no epse|has no abnormal involuntary movements|has FINE TREMORS|has FINE TREMORS IN OUTSTRETCHED HANDS|has COARSE TREMORS|has PERIORAL TREMORS|has RESTING TREMORS|has ACTION TREMORS|has INTENTION TREMOR|has MOTOR TICS|has CHOREA|has ATHETOID MOVEMENTS|has DYSTONIA|has MYOCLONUS|has reduced ARM SWING|has walks WITH A LIMP|has SHUFFLING GAIT|needs ASSISTANCE for ambulation|is on a WHEELCHAIR|is on a STRETCHER|was observed FORMICATING|was observed PULLING THREADS FROM CLOTHES|was observed SELF-MUTTERING|was observed GESTURING IN AIR|suggestive of HALLUCINATORY BEHAVIOR|demonstrates STEREOTYPIES|demonstrates MANNERISM|demonstrates WAXY FLEXIBILITY|demonstrates POSTURING|demonstrates GRIMACING|demonstrates MITMACHEN|demonstartes MITGEHEN|demonstartes GEGENHALTEN|demonstrates NEGATIVISM|demonstrates ECHOPRAXIA|demonstrates AUTOMATISM|demonstrates AMBITENDENCY|demonstartes PSYCHOLOGICAL PILLOW|Pseudoseizure could be elicited with suggestion|Movement disorder could be elicited with suggestion|demonstrates hysterical| paralysis| parasthesia|ataxia|blindness|aphonia|other conversion features|Suggestibility was tested using|falling backward suggestion|tired eyelid test|hand sticking test|circle test"]. [textarea cols="20" rows="1"]
Speech: Patients speech [select name="spontn" value="is spontaneous|is NON-SPONTANEOUS|shows PAUCITY|shows POVERTY|is MUTE|-"], [select name="rt" value="with normal reaction time|with INCREASED REACTION TIME|with DECREASED REACTION TIME|with VARIABLE REACTION TIME|-"], [select name="rate" value="normal rate|RAPID rate|SLOWED rate|PRESSURED|-"], [select name="vol" value="appropriate volume|LOUD volume|SOFT volume|WHISPHER|VARIABLE volume|MONOTONE|-"], [select name="rhythm" value="with no problems expressing self|with |with no problems expressing self, |"][checkbox value="SLURRING|STAMMERING|TREMULOUS VOICE|MUMBLING|DIFFICULTY FINDING WORDS|LOW VOCABULARY|NEOLOGISM|ECHOLALIA|PERSEVERATION|DYSPROSODY|DYSARTHRIA|ANOMIA|MOTOR APHASIA|SENSORY APHASIA|GLOBAL APHASIA|APHASIA"].[textarea cols="20" rows="1"]
Affect & Mood: Presents with [select value="appropriate eye contact|HESITANCE TO MAKE eye contact|AVOIDANT eye contact|INTENSE eye contact|INTERMITTENT eye contact|-"], [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|MASKED|"] affect which is [select value="full|RESTRICTED|BLUNTED|FLAT|EXPANSIVE|-"], [select value="even|LABILE|-"], [select value="and congruent with|and INCONGRUENT with|-"] [text] reported mood [text] (inferred as [select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"]).
Thought process: [select value="was linear|CIRCUMSTANTIAL|TANGENTIAL|COULD NOT BE ASSESSED.|"], [select value="coherent|INCOHERENT|"], [select value="and goal directed|with | "][checkbox value="PREOCCUPATIONS|RUMINATIONS|RACING THOUGHTS|FLIGHTS OF IDEAS|PROLIXITY|CLANG ASSOCIATIONS|LOOSE ASSOCIATIONS|THOUGHT BLOCKING|WORD SALAD|PERSEVERATION|NEOLOGISMS|IRRELEVANT ANSWERS|CONCRETE IDEAS"]. [textarea cols="20" rows="1"]
[select value="Thought content: no delusion on current evaluation,|Thought content: DELUSION PRESENT,|Thought content COULD NOT BE EVALUATED.|"][select value=" denies for suicidal ideations,| SUICIDAL IDEATIONS PRESENT,| DEATH WISHES PRESENT,|"][select value=" denies for homicidal ideations.| HOMICIDAL IDEATIONS PRESENT.|."] [select value="|Patient harbours "][checkbox value="WORRIES|FEARS|PREOCCUPATIONS|RUMINATIONS|SOMATIC PREOCCUPATIONS|PHOBIA|SITUATIONAL ANXIETY|LOW SELF ESTEEM|NEGATIVE COGNITIONS|SELF BLAME|EGOMANIA|MONOMANIA|HYPOCHONDRIACAL THOUGHTS|OBSESSION|COMPULSION|OVERVALUED IDEAS|PARANOID IDEAS|OVERVALUED IDEAS OF PERSECUTION|OVERVALUED IDEAS OF REFERENCE|RAISED SELF ESTEEM|GRANDIOSE IDEAS|DELUSION OF PERSECUTION|DELUSION OF REFERENCE|DELUSION OF CONTROL|DELUSION OF INFIDELITY|DELUSION OF GRANDIOSE|SOMATIC DELUSION|NIHIISTIC DELUSION|DELUSION OF GUILT|DELUSION OF POVERTY|DELUSION OF INFESTATION|DELUSION OF LOVE|DELUSIONAL MISIDENTIFICATION|CAPGRAS DELUSION|FREGOLI DELUSION|THOUGHT INSERTION|THOUGHT BROADCASTING|PRIMARY|SECONDARY|MOOD CONGRUENT|MOOD INCONGRUENT|BIZARRE|SYSTEMATIZED|BODY IMAGE ISSUES|IDEAS THAT IS TOO FAT|IDEAS THAT IS TOO THIN|SEXUAL PREOCCUPATIONS|MASTURBATION WORRIES|EMISSION WORRIES"]. [textarea cols="20" rows="1"]
Perception: [select value="No perceptual abnormalities on current evaluation.|No Hallucinations on current evaluation.|HALLUCINATION PRESENT.|Perception COULD NOT BE ASSESSED.| "][select value="|Patient "][checkbox value="demonstrates AUDITORY HALLUCINATIONS|simple |noises|music|voices|male|female|both male and female|inside head|outside head|from near|from far distance|clear|whispering|1st person|2nd person|3rd person|derogatory content|pleasant content|commanding|causing distress|patient acts on commands|patient resists commands"], [checkbox value="demonstrates VISUAL HALLUCINATIONS|demonstrates LILLIPUTIAN HALLUCINATIONS|demonstrates OLFACTORY HALLUCINATIONS|demonstrates TACTILE HALLUCINATIONS|demonstrates PHANTOM LIMB|demonstrates GUSTATORY HALLUCINATIONS|SYNESTHETIC/REFLEX HALLUCINATIONS|CENESTHETIC HALLUCINATIONS|EXTRACAMPINE|AUTOSCOPIC|MOOD CONGRUENT|MOOD INCONGRUENT|FUNCTIONAL|PSEUDOHALLUCINATION|HYPNOGOGIC|HYPNOPOMPIC|reported HYPERAESTHESIA|reported HYPOACUSIS|reported VISUAL DISTORTION|reported MICROPSIA|reported MACROPSIA|reported ILLUSION|reported FANTASTIC ILLUSION|reported PAREDOLIA|reported DEREALIZATION|reported DEPERSONALIZATION|reported DISSOCIATION|reported ABNORMAL EXPERIENCE OF PASSAGE OF TIME"]. [textarea cols="20" rows="1"]
Insight: [select value="appears fair.|appears IMPAIRED.|appears POOR.|COULD NOT BE ASSESSED.|"] [textarea cols="20" rows="1"]
Judgment: [select value="appears fair.|appears IMPAIRED.|appears POOR.|COULD NOT BE ASSESSED.|"] [textarea cols="20" rows="1"]
[select value="Cognition: appears grossly intact,|Cognition: appears grossly intact.|Cognition: appears ABNORMAL with,| Cognition: assessment DEFERRED.|Cognition: COULD NOT BE ASSESSED.|"] [checkbox value="based on the ability to attend during the interview process|understand the questions and respond|recall verifiable historical information.|with appropriate attention span and concentration|intact ability to recall recent and remote information|normal abstraction."] [textarea default="" cols="50" rows="3"]
[/conditional]
[remark]detailed cognition section start[/remark][conditional field="ismse" condition="(mse).is('MENTAL STATUS EXAMINATION:')"][checkbox name="detcog" value="Cognition:"][/conditional][conditional field="detcog" condition="(detcog).is('Cognition:')&&(mse).is('MENTAL STATUS EXAMINATION:')"]
[checkbox memo="orientation" value="Patient was DISORIENTED to|person|place|time|day of week|date|month|year"]
[checkbox value="During interview patient appeared|attentive.|DISTRACTIBLE.|APATHIC."][checkbox memo="attention and concentration" value=" Attention and concentration was assessed using|digit span|serial seven subtraction from 100|serial three subtraction from 30|serial one subtraction for 20|naming of month backwards|naming of days of weeks backwards|spelling word backwards|. Attention and concentration was intact.|. Had PROBLEMS WITH ATTENTION AND CONCENTRATION."] [textarea cols="20" rows="1"]
[checkbox memo="perseveration" value="Perseveration was assessed using|copying of changing patterns|repeating number letter combination|tapping a letter A|. Did not show perseveration|. SHOWED SIGNS OF PERSEVERATION"] [textarea cols="20" rows="1"]
[checkbox memo="immediate memory" value="Immediate recall was tested by|3 word repetition|brief paired associate test|learning of name and address|figure drawing|. Immediate memory was intact|. IMMEDIATE MEMORY WAS IMPAIRED"] [textarea cols="20" rows="1"]
[checkbox memo="recent memory" value="Recent memory was tested by|delayed 3 word repetition|delayed brief paired associate recall|delayed recall of name and address|delayed figure drawing|asking the patient to describe last meal|. Recent memory was intact|. RECENT MEMORY WAS IMPAIRED"] [textarea cols="20" rows="1"]
[checkbox memo="remote memory" value="Remote memory was tested by|recall of historic events|recall of personal verifiable information|. Remote memory was intact|. REMOTE MEMORY WAS IMPAIRED"] [textarea cols="20" rows="1"]
[checkbox memo="language" value="Language was assessed by|having him/her write|having him/her repeat sentences|observing the patients fluency|having him/her carry our commands|having him/her name parts of objects|having him/her read and comprehend|. The patient did not have any|aphasia|alexia|agraphia|. The patient showed signs of|APHASIA|ALEXIA|AGRAPHIA"] [textarea cols="20" rows="1"]
[checkbox memo="agnosia" value="Agnosia was assessed for by|writing letter on patients hand|having him/her identify coins|having him/her name his fingers|having him/her point to right and left body parts|. The patient did not have agnosia.|. The patient showed signs of AGNOSIA."] [textarea cols="20" rows="1"]
[checkbox memo="apraxia" value="Apraxia was assessed for by asking the patient to perform action|such as blow out a match stick(buccofacial)|use a hammer(limb)|swing a bat(body)|act of toothbrushing(ideational)|draw or copy figure(s)|draw a clock face|. The patient did not have apraxia.|. The patient showed signs of APRAXIA."] [textarea cols="20" rows="1"]
[checkbox memo="calculation" value="Considering patients educational background calculation ability was assessed using|simple addition and multiplication|slightly difficult arithmetic|without using paper and pencil|difficult arithmetic using paper and pencil|. Patient did not show dyscalculia.|. Patient showed signs of DYSCALCULIA."] [textarea cols="20" rows="1"]
[checkbox memo="frontal lobe function" value="Executive functions were assessed using|think about similarities|proverb interpretation|set generation (letter)|set generation (animal)|Luria motor test|Go-no-go test|frontal release reflexes"] [textarea cols="20" rows="1"]
[checkbox memo="visual agnosia" value="Visual agnosia was assessed for by|matching test|incomplete letter test|matching dissimilar objects|having him/her identify faces of famous people|color naming|color pointing|global letter test|mixed figure test|. The patient did not have visual agnosia.|. The patient showed signs of VISUAL AGNOSIA."] [textarea cols="20" rows="1"]
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