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30 Cards in this Set

  • Front
  • Back
Case Presentation Order
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
Diagnosis
Somatic Treatments
Past Treatments
Hospitalizations
Previous SI
Previous HI
Alcohol and Drug History
What has worked best
PMH
Medical Problems
Medications
Allergies
Seizures
Head Injuries
Social History
Developmental History
Educational Level
Current Family
Employment and Disability
Military History
Legal History
Abuse History
Case Presentation Differential Diagnosis
Organic Etiologies
Psychosis
Anxiety
Affective
Substance
Somatoform
ADHD
TD
BIQ/MR
Organic Etiology Differential Diagnosis
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
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
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
Physical conditioning
Nutritional status
Stable medical problems
Biological Functioning Liabilities
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
Intelligence
Willingness to accept help
Religion
Psychological Formulation Liabilities
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
Skilled
Employed
Educated
Financially solvent
Needed by someone
Social Formulation Liabilities
Stresses (occupational, partner, etc)
Lacking support network
Case Presentation’s Workup Plan
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…”)
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
Identification of the Goals of Treatment (both short- and long-term)
Psychoeducation
Biological
Psychological
Social
Short-Term Treatment Goals
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
Development of autonomy
Responsibility awareness
Foster and further insight
Social skills training
Elements of Psychoeducation
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
Somatic treatments
Light therapy
Goals of Psychological Treatments
Foster autonomy, insight, and responsibility awareness
Psychodynamic Psychotherapy
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 factors”
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
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
“What you think influences what you feel”
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
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
Environmental manipulation (partial, ward, outpatient)
Work/school limitations
Psychoeducation for significant others
OT for work/rest/play balance and life skills learning