Psychiatry
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Consult requested by [select name="MD" value="|Dr. Meadors|Dr. Paschall|Dr. Richards|Dr. Willers"].

Reason for consultation: [checkbox value="failed post-partum depression screen |trauma history|signs of depression"].

Reliability and sources of history:
[checkbox value="patient was able to answer questions appropriately and appeared to be reliable historian|patient was only able to provide a limited history due to apparent"] [select name="impairments"value="|cognitive impairments|communication difficulties related to deafness|speech disturbance| (dysarthria)|speech disturbance (dysphasia)|speech disturbance (dysphonia)|cognitive dysfunction (delirium, dementia)| distraction (due to pain)|distraction (due to emotional distress)|thought disorder|manipulative behaviors|intentional evasiveness|low intellectual functioning|maladaptive personality traits|lack of awareness of details related to their illness|somnolence"][checkbox value="the patient is non-English speaking, language line/translater used for interview|the patient is intubated and unable to provide history|the patient is paranoid and uncooperative with efforts to gather history|the patient is hard of hearing|the patient is confused|the patient is frequently noncommittal|provided history contradicts what was reported|earlier|reported history has been inconsistent over time|history considered unreliable|limited history in chart|limited history available|history unobtainable| A family member was contacted, but unable to provide additional information|available medical records are scant and did not contain and did not contain all necessary information"].

History of Present Illness: The patient is a [ ] y/o F, with past psychiatric history of [ ], pregnancy complicated by who was admitted at [ ] weeks EGA for [onset of labor, induction of labor, preterm labor, primary cesarean section, repeat cesarean section, preeclampsia, vaginal bleeding, premature rupture of membranes, vaginal bleeding, hyperemesis, preterm labor, decreased fetal activity, observation and evaluation for fetal status, observation and evaluation for medical complications, observation and evaluation for obstetric complications], now [x] day status post [uncomplicated] [spontaneous vaginal , cesarean] [preterm, term, postterm] delivery of [male,female] singleton[with postpartum complications of, complicated by] [infection, abnormal lab, hematoma, spinal headache today, psychological maladaptation, drug/transfusion reaction, eclampsia, hemorrhage, phlebitis, morbidity, fever][. Pregnancy complicated by][no prenatal care, late prenatal care, medical history of, obstetrical history of, binge drinking during pregnancy, nicotine use during pregnancy, physical abuse during pregnancy, significant anxiety during pregnancy, significant depression during pregnancy, suicidal ideation during pregnancy, suicide attempt during pregnancy, psychotic symptoms during pregnancy].

Review of Symptoms

Medical ROS:
[textarea name="medROS" default="sample text"]

Depression: [comment memo="(at least 4 for 2 weeks)"][checkbox name="depsx" value="Sleep disturbances|Decreased interest/pleasure in enjoyable activities|Guilt/Worthlessness|Decreased energy/Fatigue|Decreased concentration|Decreased appetite|Increased appetite|Psychomotor retardation|Psychomotor agitation|Thoughts of death|These symptoms have been present more days than not for"][textarea name="deptext" default=" "]


Dysthymia:[comment memo="(2 out of 6 for at least 2 years)"][checkbox name="dyssx" value="Decreased or increased appetite|Decreased concentration|Hopelessness|Decreased energy|Worthlessness|Sleep disturbances"]
[textarea name="dystext" default="sample text"]

Manic Episode
[checkbox name="mainmanSx" value="Persistently elevated mood|Persistently irritable mood|Lasting at least one week|Hospitalization was necessary"][comment memo="(3 or more of the following symptoms during the mood episode, 4 or more symptoms if mood is only irritable)"][checkbox name="mansx" value="Distractibility|Involvement in high risk or pleasurable activities|Grandiosity or inflated self-esteem|Flight of ideas or racing thoughts|Increased goal directed activity|Sleep deficit|Talkativeness"].
[textarea name="mantext" default="These symptoms last occurred XX and lasted for about XX."]

Generalized Anxiety (Symptoms for at least 6 months
[checkbox name="variable_1" value="Excessive worry occurring more days than not|Difficulty controlling worry"]
GAD cont. (3 of the following symptoms)
[checkbox name="variable_1" value="Muscle tension|Fatigue|Difficulty concentrating|Restless or feeling on edge|Irritability|Sleep disturbance"]
[textarea name="variable_1" default=" "]

Panic Disorder
[checkbox name="variable_1" value="recurrent unexpected panic "]
(with at least 4 of the following symptoms)
[checklist name="variable_1" value="Palpitations|Chest pain|Nausea|SOB|Choking sensation|Dizziness|Paresthesias|Hot/cold waves|Fear of dying|Fear of going crazy|Sweating|Shaking|Derealization/depersonalization"]

At least one panic attack has been followed by 1 month of one of the following:
[checklist name="variable_1" value="Fear of another panic attack occurring|persistent worry about the implications of the attack|change in behavior because of the panic attacks"]
[textarea name="variable_1" default="sample text"]

Agoraphobia:
[checkbox name="variable_1" value="Fear of being in places where escape may be difficult or embarrassing|Situations are avoided or endured with marked distress"]
[textarea name="variable_1" default="sample text"]


PTSD (Symptoms lasting at least 6 months)
[checklist name="variable_1" value="Experienced traumatic event"]
[checklist name="variable_1" value="Re-experiences event via memories, dreams and/or flashbacks|Avoids stimuli associated with the event|Negative beliefs about self|Negative beliefs about the world|Diminished interest in activities|Sleep disturbances|Irritability|Difficulty concentrating|Hyper-vigilance|Exaggerated startle response"]
[textarea name="variable_1" default="sample text"]

Attention deficit hyperactivity disorder
(At least 6 symptoms from criteria 1 or 2 if under 17 yo, At least 5 if over 17 yo)

Criteria 1: Organization/Inattention
[checkbox name="variable_1" value="Can't organize tasks|Loses things needed for tasks|Has problems finishing tasks|Poor focus|Easily distracted|Doesn't listen|Forgets easily|Makes careless mistakes|Avoids tasks requiring concentration"]

Criteria 2: Impulsivity/Hyperactivity
[checkbox name="variable_1" value="Talks too much|Blurts out answers|Interrupts others|Can't play quietly|Fidgets and squirms|Leaves seat|Restlessness|Always on the go|Can't wait for their turn"]

Criteria 3:
[checklist name="variable_1" value="Some symptoms present before the age of 12"]

Criteria 4:
[checklist name="variable_1" value="Symptoms occur in 2 or more settings"]
[textarea name="variable_1" default="sample text"]

Substance Use Disorder:
[checklist name="variable_1" value="Tolerance to substance|Symptoms of substance withdrawal|Loss of control of substance use"]
[textarea name="variable_1" default="sample text"]

OCD:
[textarea name="variable_1" default="sample text"]

Psychosis:
[textarea name="variable_1" default="sample text"]

Eating Disorder:
[textarea name="variable_1" default="sample text"]

Personality Disorders:
[textarea name="variable_1" default="sample text"]

Other Notes:
[textarea name="variable_1" default="sample text"]



MDE: Patient denies/reports low mood, insomnia/hypersomnia, increased/decreased appetite, weight gain/weight loss, difficulty concentrating, low energy, fatigue, decreased pleasure in previously pleasurable activities, and suicidal thoughts with/without intent and plan to [plan]. These symptoms have been present more days than not for [duration].

Mania: Patient denies/reports sustained elevated and euphoric or irritable mood, increased energy levels with a decreased need to sleep (reports average of--hours of sleep per night), racing thoughts, increased goal directed activities, pressured speech, inflated self esteem or grandiosity, more talkative than usual or pressure to keep talking, easily distracted, and excessive involvement in activities with a high likelihood of painful consequences (shopping sprees, gambling, promiscuity, reckless driving). Patient reports that these symptoms last occurred [] and lasted for about [].

Psychosis: Patient denies/endorses hearing voices or seeing things that are not real which last occurred [] and lasted []. Patient denies/reports feeling as if people are following him, stalking him, talking about him or trying to hurt him. Patient denies/reports feeling as if he can read minds or that others can hear his thoughts. Patient denies/reports feeling that the world is sending them subliminal messages or that TV shows are specifically referring to the him. Patient reports that these symptoms last occurred [] and lasted for about [].

Panic Attack: Palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, a feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, feelings of unreality (derealization) or being detached from oneself (depersonalization), fear of losing control or going crazy, fear of dying, numbness or tingling sensations (paresthesias), chills or hot flushes. These attacks occur at a frequency of about [] and last occurred on [].

Panic Disorder: Patient denies/endorses excessive worrying about future unexpected panic attacks and often avoids situations that may trigger a panic attack.

GAD: Patient denies/reports excessive anxiety and worry about a number of events or activities (such as work or school performance) with difficulty controlling the worrying. In addition to worrying the patient reports restlessness, feeling keyed up or on edge, easily fatigued, concentration difficulties, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep. The patient reports these symptoms occurring at a frequency of [] for a duration of [].

PTSD: Patient denies/reports a history of trauma where the patient was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence by either direct exposure, witnessing the event, learning that a relative or close friend was exposed to a trauma, or indirectly by exposure to aversive details of the trauma. In addition the patient reports that the traumatic event is persistently re-experienced by intrusive thoughts, nightmares, flashbacks, emotional distress after exposure to traumatic reminders, or physical reactivity after exposure to traumatic reminders. Due to the trauma the patient avoids trauma-related stimuli after the trauma. Patient endorses negative thoughts or feelings that began or worsened after the trauma as evidenced by an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities, feeling isolated, or difficulty experiencing positive affect. Patient endorses trauma-related arousal and reactivity that began or worsened after the trauma as evidenced by irritability or aggression, risky or destructive behavior, hypervigilance, heightened startle reaction, difficulty concentrating, or difficulty sleeping

OCD: Patient denies/reports obsessive or intrusive thoughts and/or compulsions.


Medical/Surgical History:
Para: [], Gravida:[]


Psychiatric History:
[First mental health contact at age] [] [for]
Past diagnoses: []
Inpatient treatment: [None]
Outpatient treatment: [None]
Self/other-harm: suicide attempts-[none] , non-suicidal self-injury-[none] , homicidality-[none] , history of physical violence-[none]
Past psychiatric medication trials: [none]



Family Psychiatric History:
[No known history of psychiatric illness, substance abuse, suicide.]

Social History:
Childhood: []
Family: []
Relationship status: []
Lives with: []
Support system includes: []
Employment:[]
Highest level of education: []
[Military history:] []
Trauma history: [denies history of sexual, physical or emotional abuse]

A & D History:
Current: []
Past:[]
Plan:
-Counseling/discussion at bedside with [select value="patient|partner|family member|support person"] re:
treatment options, including non-pharmacological and pharmacological approaches, treatment recommendations, and intended outcomes of treatment.

-Discussion included [checkbox value="recommendations for psychotherapy to address XXXXX|recommendations for trial of XXXXX for XXXX disorder|analysis of risks versus benefits to patient| and infant while breast-feeding|of treatment of psychiatric disorder with medication|consideration of psychological and physiological benefits of breast-feeding|possibility of foregoing or stopping treatment with medication while breastfeeding|consideration of potential adverse effects of untreated maternal mental illness to maternal-child bonding|higher risk of decompensation without pharmacological management| potential risks to cognitive and behavioral development of infant with exposure through breast milk| and acknowledgement of the uncertainty of possible risks and harms to infant due to lack of available evidence"].
[checkbox value="Strategies undertaken to minimize exposure and risks to infant including:"][checkbox value= "medication selection, lowest effective dose, and timing of dose|need for close outpatient follow-up for management of psychiatric medication|need for coordination with pediatrician and close monitoring of breastfeeding infant for potential side effects, including sedation and EPS"].
-[checklist value="Patient|partner|family member|support person"] demonstrated understanding and agreed to plan for
[checkbox value="trial of medication|psychotherapy|follow-up and management with outpatient mental health|referral to outpatient mental health for further evaluation and formulation of treatment plan"] as outlined above.
Consult requested by .

Reason for consultation: .

Reliability and sources of history:
.

History of Present Illness: The patient is a [ ] y/o F, with past psychiatric history of [ ], pregnancy complicated by who was admitted at [ ] weeks EGA for [onset of labor, induction of labor, preterm labor, primary cesarean section, repeat cesarean section, preeclampsia, vaginal bleeding, premature rupture of membranes, vaginal bleeding, hyperemesis, preterm labor, decreased fetal activity, observation and evaluation for fetal status, observation and evaluation for medical complications, observation and evaluation for obstetric complications], now [x] day status post [uncomplicated] [spontaneous vaginal , cesarean] [preterm, term, postterm] delivery of [male,female] singleton[with postpartum complications of, complicated by] [infection, abnormal lab, hematoma, spinal headache today, psychological maladaptation, drug/transfusion reaction, eclampsia, hemorrhage, phlebitis, morbidity, fever][. Pregnancy complicated by][no prenatal care, late prenatal care, medical history of, obstetrical history of, binge drinking during pregnancy, nicotine use during pregnancy, physical abuse during pregnancy, significant anxiety during pregnancy, significant depression during pregnancy, suicidal ideation during pregnancy, suicide attempt during pregnancy, psychotic symptoms during pregnancy].

Review of Symptoms

Medical ROS:


Depression: (at least 4 for 2 weeks)


Dysthymia:(2 out of 6 for at least 2 years)


Manic Episode
(3 or more of the following symptoms during the mood episode, 4 or more symptoms if mood is only irritable) .


Generalized Anxiety (Symptoms for at least 6 months

GAD cont. (3 of the following symptoms)



Panic Disorder

(with at least 4 of the following symptoms)


At least one panic attack has been followed by 1 month of one of the following:



Agoraphobia:




PTSD (Symptoms lasting at least 6 months)




Attention deficit hyperactivity disorder
(At least 6 symptoms from criteria 1 or 2 if under 17 yo, At least 5 if over 17 yo)

Criteria 1: Organization/Inattention


Criteria 2: Impulsivity/Hyperactivity


Criteria 3:


Criteria 4:



Substance Use Disorder:



OCD:


Psychosis:


Eating Disorder:


Personality Disorders:


Other Notes:




MDE: Patient denies/reports low mood, insomnia/hypersomnia, increased/decreased appetite, weight gain/weight loss, difficulty concentrating, low energy, fatigue, decreased pleasure in previously pleasurable activities, and suicidal thoughts with/without intent and plan to [plan]. These symptoms have been present more days than not for [duration].

Mania: Patient denies/reports sustained elevated and euphoric or irritable mood, increased energy levels with a decreased need to sleep (reports average of--hours of sleep per night), racing thoughts, increased goal directed activities, pressured speech, inflated self esteem or grandiosity, more talkative than usual or pressure to keep talking, easily distracted, and excessive involvement in activities with a high likelihood of painful consequences (shopping sprees, gambling, promiscuity, reckless driving). Patient reports that these symptoms last occurred [] and lasted for about [].

Psychosis: Patient denies/endorses hearing voices or seeing things that are not real which last occurred [] and lasted []. Patient denies/reports feeling as if people are following him, stalking him, talking about him or trying to hurt him. Patient denies/reports feeling as if he can read minds or that others can hear his thoughts. Patient denies/reports feeling that the world is sending them subliminal messages or that TV shows are specifically referring to the him. Patient reports that these symptoms last occurred [] and lasted for about [].

Panic Attack: Palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, a feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, feelings of unreality (derealization) or being detached from oneself (depersonalization), fear of losing control or going crazy, fear of dying, numbness or tingling sensations (paresthesias), chills or hot flushes. These attacks occur at a frequency of about [] and last occurred on [].

Panic Disorder: Patient denies/endorses excessive worrying about future unexpected panic attacks and often avoids situations that may trigger a panic attack.

GAD: Patient denies/reports excessive anxiety and worry about a number of events or activities (such as work or school performance) with difficulty controlling the worrying. In addition to worrying the patient reports restlessness, feeling keyed up or on edge, easily fatigued, concentration difficulties, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep. The patient reports these symptoms occurring at a frequency of [] for a duration of [].

PTSD: Patient denies/reports a history of trauma where the patient was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence by either direct exposure, witnessing the event, learning that a relative or close friend was exposed to a trauma, or indirectly by exposure to aversive details of the trauma. In addition the patient reports that the traumatic event is persistently re-experienced by intrusive thoughts, nightmares, flashbacks, emotional distress after exposure to traumatic reminders, or physical reactivity after exposure to traumatic reminders. Due to the trauma the patient avoids trauma-related stimuli after the trauma. Patient endorses negative thoughts or feelings that began or worsened after the trauma as evidenced by an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities, feeling isolated, or difficulty experiencing positive affect. Patient endorses trauma-related arousal and reactivity that began or worsened after the trauma as evidenced by irritability or aggression, risky or destructive behavior, hypervigilance, heightened startle reaction, difficulty concentrating, or difficulty sleeping

OCD: Patient denies/reports obsessive or intrusive thoughts and/or compulsions.


Medical/Surgical History:
Para: [], Gravida:[]


Psychiatric History:
[First mental health contact at age] [] [for]
Past diagnoses: []
Inpatient treatment: [None]
Outpatient treatment: [None]
Self/other-harm: suicide attempts-[none] , non-suicidal self-injury-[none] , homicidality-[none] , history of physical violence-[none]
Past psychiatric medication trials: [none]



Family Psychiatric History:
[No known history of psychiatric illness, substance abuse, suicide.]

Social History:
Childhood: []
Family: []
Relationship status: []
Lives with: []
Support system includes: []
Employment:[]
Highest level of education: []
[Military history:] []
Trauma history: [denies history of sexual, physical or emotional abuse]

A & D History:
Current: []
Past:[]
Plan:
-Counseling/discussion at bedside with re:
treatment options, including non-pharmacological and pharmacological approaches, treatment recommendations, and intended outcomes of treatment.

-Discussion included .
.
- demonstrated understanding and agreed to plan for
as outlined above.

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