Case Note

[comment memo="The ICD-10 codes are here http://apps.who.int/classifications/icd10/browse/2010/en#/V"]

Subjective:

When asked to rate how things have been over the last week, patient name reported that [select name="Q1" value="things have been unremarkable.|there have been some difficulties.|life has been pretty good.|"][conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"] When asked to elaborate, patient name reported concerns with: [conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"][checkbox name="lastweek" value="the primary support group|the social environment|education|work|housing|finances|access to health care services|legal justice system|psycho-social functioning and their environment"].[/conditional] [textarea cols=80 rows=5 default="additional comments"]

Neurovegetative symptoms -- sleep was [select value="good|fair|poor|terrible"]; appetite was [select value="good|fair|poor|terrible"]; concentration was [select value="good|fair|poor|terrible"]; and energy levels were [select value="good|fair|poor|terrible"]. 

Attitude towards treatment -- [select value="unable to rate|it's highly beneficial.|it's occasionally helpful.|it's not helpful."]

Objective:

- Mental Status Examination -

General: [select value="alert and oriented in all spheres|vigilant|drowsy|lethargic|asleep|sleepy|confused|disoriented"].
Appearance: [select value="appropriately dressed|meticulous grooming|disheveled|inappropriately dressed|neglected|unremarkable"].
Posture: [select value="normal|relaxed|stooped|stiff|shaky|slouched|crouched|affected"].
Gait: [select value="normal|brisk|slow|hesitant|shuffling|dancing|ataxic|uncoordinated"].
Behaviour - general: [select value="cooperative|hostile|defensive|unguarded|secretive|evasive|suspicious|paranoid|apathetic|warm|open|easy-going"].
Behaviour - stability: [select value="calm|agitated|unstable|volatile"].
Behaviour - interactivity: [select value="warm|interactive|withdrawn|cold"].
Behaviour - eye contact: [select value="good|fair|fleeting|avoidant"].
Mood/Affect - stated: [select value="euthymic|depressed|anxious|irritable|euphoric|sad|elated|positive|negative|miserable"].
Mood/Affect - emotional range: [select value="normal|broad|restricted"].
Mood/Affect - intensity: [select value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select value="mood is congruent with affect|mood and affect are not congruent"].
Speech - [select value="articulate|spontaneous|verbose|talkative|expansive|impoverished|mumbled|aphasic"].
Thought form and content: [select value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select value="no difficulty with attention or concentration|had some attention and concentration problems during the encounter"].
Perception - general: [select value="normal perception|preoccupied with thoughts|preoccupied with delusions|attending to hallucinations|perception grossly disturbed"].
Cognition/Memory: [select value="normal|fair|superior|poor"].
Cognition/Memory - abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select value="fair|poor|good"].
Insight: [select value="sound|unrealistic|lacking|fair|poor|good"].
Suicide: [select value="no current ideation or intent|constant rumination about suicide|thinking about it, but without serious intent or plan|resolved to suicide"].
Violence: [select value="no current ideation or intent|actively wanting to harm others"].
Patient is currently assessed to be at [select value="low|moderate|high"] risk for self injury.
Patient is currently assessed to be at [select value="low|moderate|high"] risk of harm to others.

[textarea cols=80 rows=5 default="On observing patient name I also noted..."]

Assessment:

Working Diagnosis -- [checkbox name="diagnosis" value="F00-F09 Organic, including symptomatic, mental disorders|F10-F19 Mental and behavioural disorders due to psychoactive substance use|F20-F29 Schizophrenia, schizotypal and delusional disorders|F30-F39 Mood (affective) disorders|F40-F48 Neurotic, stress-related and somatoform disorders|F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors|F60-F69 Disorders of adult personality and behaviour|F70-F79 Mental retardation|F80-F89 Disorders of psychological development|F90-F98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence|F99-F99 Unspecified mental disorder|unable to rate/assessment incomplete"]

[link url="http://apps.who.int/classifications/icd10/browse/2010/en#/V" memo="ICD-10 diagnoses"] 
Formulation -- [textarea cols=80 rows=5 default="patient presented today with this problem, because of this reason."]

Global Assessment Rating: [checkbox name="GAR" value="100-91 Doing very well|90-81 Doing well|80-71 Doing all right - minor impairment|70-61 Some problems - in one area only|60-51 Some noticeable problems – in more than one area |50-41 Obvious problems - moderate impairment in most areas or severe in one area|40-31 Serious problems - major impairment in several areas and unable to function in one area|30-21 Severe problems - unable to function in almost all situations|20-11 Very severely impaired - so impaired that considerable supervision is required for safety|10-1 Extremely Impaired - so impaired that constant supervision is required for safety "]

Plan:

Treatment -- [textarea cols=80 rows=5 default="because of the above formulation I treated the patient with CBT"]

Prognosis -- At the time of writing, patient name's prognosis is [select value="good|fair|poor|uncertain"].

Treatment goals -- In terms of future treatment, [textarea cols="50" rows="5" default="based on todays treatment, I will therefore continue with CBT, or change to another modality, and book apt with the doctor"].

Next appointment -- patient name's next appointment is scheduled for [textarea cols=10 rows=1 default="day"], [textarea cols=10 rows=1 default="date"] at [textarea cols=10 rows=1 default="time"].

[textarea cols="50" rows="5" default="Final notes"]