Follow-Up Psych Consult

DATE OF CONSULTATION: [date name="variable_1" default=""]

C/C:
The patient was seen for a follow-up behavioral health consultation in room [text name="variable_2" default=""]. Consultation was requested due to [text name="variable_3" default=""].

HPI:
[textarea name="variable_4" default="As per RN, "]
[textarea name="variable_5" default="As per BH, "]

ROS: 
[text name="variable_8" default="No fever/headache/malaise/anorexia."] 
[textarea name="variable_6" default=""]
[text name="variable_7" default="All other systems were reviewed and were negative except as mentioned in HPI."]

PSYCHIATRIC EXAM:
- CONSTITUTIONAL: 
* Vital Signs: TEMP: [text name="variable_10" default=""] HR: [text name="variable_11" default=""] RR: [text name="variable_12" default=""] SPO2: [text name="variable_13" default=""] BP: [text name="variable_14" default=""]
* General Appearance: [select name="variable_57" value="Well kempt|Poorly groomed|Disheveled"], [select name="variable_58" value="Alert,|Lethargic,|Obtunded.|In deep sleep."] [select name="variable_59" value="Calm,|Anxious,|Restless,|Angry,|Belligerent,|"] [select name="variable_60" value="Cooperative.|Uncooperative.|"] [text name="variable_76" default=""]

- MSK: 
* [select name="variable_20" value="Normal|Abnormal"] Muscle Strength, [select name="variable_23" value="Normal|Abnormal"] Tone, [select name="variable_22" value="Without|With"] Abnormal Movements, [select name="variable_22" value="Without|With"] Atrophy. [text name="variable_19" default=""]
* Gait: [select name="variable_17" value="Stable|Unstable"], Station: [select name="variable_18" value="Stable|Unstable"].

- PSYCH: 
* Speech: Rate: [select name="variable_24" value="Normal|Slow|Rapid|Pressured|Could not assess"]. Volume: [select name="variable_25" value="Normal|Low|High|Could not assess"]. Articulation: [select name="variable_26" value="Well-articulated|Fragmented|Could not assess"]. Coherence: [select name="variable_27" value="Coherent|Incoherent|Could not assess"]. Spontaneity: [select name="variable_28" value="Spontaneous|Non-spontaneous|Mutism|Could not assess"]. Abnormalities: [select name="variable_29" value="Without abnormalities|Slurred|Hesitant|Aphasic|Could not assess"]. [text name="variable_93" default=""]

* Thought Processes: [select name="variable_30" value="Organized|Disorganized|Could not assess"], [select name="variable_31" value="Rational|Irrational|Could not assess"].

* Associations: [select name="variable_32" value="Within normal limits|Flight of ideas|Loose|Tangential|Circumstantial|Could not assess"].

* Abnormal/psychotic thoughts: [select name="variable_33" value="No suicial ideations, intents, or plans|Suicidal ideation present|Suicidal intent present|Suicidal plan present|Could not assess"]. [select name="variable_34" value="No homicidal ideation or plans|Homicidal ideation present|Homicidal plan present|Could not assess"]. [select name="variable_35" value="No hallucinations|Hallucinations present|Could not assess"]. [select name="variable_36" value="No Delusions|Delusions present|Could not assess"]. [select name="variable_37" value="No severely disorganized thought processes|Severely disorganized thought processes present|Could not assess"]. [text name="variable_94" default=""]

* Judgement: [select name="variable_38" value="Good|Fair|Poor|Could not assess"]. Insight: [select name="variable_39" value="Good|Fair|Poor|Could not assess"].

* Oriented to [checkbox name="variable_40" value="Person|Place|Time|Situation"].

* Recent memory: [select name="variable_41" value="Good|Fair|Poor|Could not assess"]. Remote memory: [select name="variable_42" value="Good|Fair|Poor|Could not assess"].

* Attention span: [select name="variable_43" value="Good|Fair|Poor|Could not assess"]. Concentration: [select name="variable_44" value="Good|Fair|Poor|Could not assess"].

* Language: [select name="variable_45" value="Fluent|Fair|Poor|Could not assess"].

* Fund of knowledge: [select name="variable_46" value="Good|Fair|Poor|Could not assess"].

* Mood: [select name="variable_47" value="Euthymic|Happy|Sad|Depressed|Desperate|Worried|Anxious|Irritable|Agitated|Angry|Elated|Euphoric|Could not assess|"]. Affect: [select name="variable_48" value="Euthymic|Dysphoric|Happy|Sad|Depressed|Desperate|Worried|Anxious|Irritable|Agitated|Angry|Elated|Euphoric|Expansive|Detached|Could not assess affect type|"],  [select name="variable_50" value="Congruent|Noncongruent|Could not assess congruence"].

LABS AND DIAGNOSTIC STUDIES: 
QTc [text name="variable_51" default=""] milliseconds on [date name="variable_52" default=""]. 
[textarea name="variable_53" default=""]

DIAGNOSES/ASSESSMENT:
[select name="variable_88" value="|1.|2.|3.|4.|5.|6.|7.|8."] [select name="variable_61" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_62" value="|mild|moderate|severe"] [select name="variable_63" value="|single episode|recurrent"] [select name="variable_64" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_65" default=""]
[select name="variable_89" value="|2.|3.|4.|5.|6.|7.|8."] [select name="variable_66" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_67" value="|mild|moderate|severe"] [select name="variable_68" value="|single episode|recurrent"] [select name="variable_69" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_70" default=""]
[select name="variable_90" value="|3.|4.|5.|6.|7.|8."] [select name="variable_71" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_72" value="|mild|moderate|severe"] [select name="variable_73" value="|single episode|recurrent"] [select name="variable_74" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_75" default=""]
[select name="variable_91" value="|4.|5.|6.|7.|8."] [select name="variable_77" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_78" value="|mild|moderate|severe"] [select name="variable_79" value="|single episode|recurrent"] [select name="variable_80" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_81" default=""]
[select name="variable_92" value="|5.|6.|7.|8."] [select name="variable_82" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_83" value="|mild|moderate|severe"] [select name="variable_84" value="|single episode|recurrent"] [select name="variable_85" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_86" default=""]
[select name="variable_101" value="|6.|7.|8."] [select name="variable_119" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_102" value="|mild|moderate|severe"] [select name="variable_103" value="|single episode|recurrent"] [select name="variable_104" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_105" default=""]
[select name="variable_106" value="|7.|8."] [select name="variable_107" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_108" value="|mild|moderate|severe"] [select name="variable_109" value="|single episode|recurrent"] [select name="variable_110" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_111" default=""]
[select name="variable_112" value="|8."] [select name="variable_113" value="|Major depressive disorder|Anxiety disorder|Generalized anxiety disorder|Bipolar disorder|Schizoaffective disorder|Schizophrenia|Schizophreniform disorder|Psychotic disorder|Delirium|Brief psychotic disorder|Tobacco use disorder|Alcohol use disorder|Drug use disorder|Cannabis use disorder|IDD/MR|Borderline personality disorder|Mood disorder|Methamphetamine abuse disorder|Heroin use disorder|Cocaine use disorder|Post-traumatic stress disorder|Nightmare disorder|Obsessive compulsive disorder|Impulse control disorder|Conversion disorder"] [select name="variable_114" value="|mild|moderate|severe"] [select name="variable_115" value="|single episode|recurrent"] [select name="variable_116" value="|depressed type|manic type|bipolar type|mixed type|unspecified type"] [text name="variable_117" default=""]
[textarea name="variable_118" default=""]

PLAN:
[textarea name="variable_55" default=""]

ATTENDING PHYSICIAN'S NOTES/COMMENTS:
[textarea name="variable_56" default=""]