wovenmelta

精神科admission note

Acceptation Time:

Informant:

Basic Data:

Chief Problems:

Present Illness:

Past History:

Birth: full-term

Development: no delay

Education:

Occupation:

Military: completed

Interpersonal relationship: fair

Pre-morbid personality:

Systemic Disease:

Drug allergy: denied

Substance Abuse History:

Denied smoking history

Denied alcohol consumption

Denied other substance use history

Family History:

Key person

Relationship: fair

Support: fair

Mental Status Examination:

I.            Appearance, behavior, and attitude

A.         Normal, neat and tidy, angry, sad , unkempt(未梳理不整齊), well-dressed, “spacing out”, grimacing, expressionless, apprehensive(憂慮擔心), bewildered, anxious

B.         No disorganized behavior, pacing on the floor, stupor, excitement, dyskinetic movement, tremor of the hands, motionless, screaming, compulsive behavior, psychomotor agitation, psychomotor retardation, echopraxia(模仿動作), waxy flexibility, tics, posturing, mannerism(持續做有意義的動作?)

C.         Cooperative, uncooperative, hostile (敵視), refused to answer any questions, trying to answer questions, la belle indifference (轉化症，對自己之病漠不關心), eager (慾望的), over-eager, apathetic (無感情)

II.         Stream of Thought

A.         Coherent and relevant, incoherence (disorganized speech, loosening of association), circumstantial thought, tangential thought, flight of idea, fragmented idea, word salad, neologisms, magical thinking, prelogical idea, paralogical idea, clang association.

B.         No mutism, blocking slow mental activity, pressured speech, spontaneous speech, perseveration

III.       Affect (客觀) and Mood (長期性的，主觀的)

A.         Affect

                             i.                Stable, unstable (labile)

                           ii.                Appropriate, inappropriate

                          iii.                Range: flat, branded, restrictive, shallow, narrow, within normal ranges, super sharp

B.         Depressed (dysthymic), normal (euthymic, even), elated

IV.      Contents of thought

A.         Delusion of reference (什麼事都和他有關) delusion of being spied, delusion of persecution (被害妄想) delusion of influence, delusion of grandeur (自我浮誇), feeling of being singled out, somatic delusion.

B.         Suicidal idea, suicidal formulation, suicidal planning, suicidal attempt

C.         Homicidal ideas (殺別人)

D.         No obsession, phobia, preoccupation, delusion of jealousy, nihilistic idea, delusion of poverty, déjà vu (明明第一次遇到，卻有似曾相識的感覺) , jamais vu.

V.         Perception 知覺

A.         Hallucinations (visual, auditory, tactile, olfactory, gustatory) illusion

VI.      Sensorium and Mental Capacities

A.         Clear (not clouded) confused, stupor, semicomatose, comatose.

B.         Oriented (to time, place and person 喪失的先後順序) fund of general information: fair, attention span: fair (可以calculation測) , calculation ability: fair, serial subtraction of 7 from 100 (例：您身上有100元，買一支筆7元，買一支剩多少，再買一支呢？中途勿提示93、86、79、72、65或她講的答案；也不能提示剛剛的7元。買五支剩多少。), abstract (figurative) thinking tested by similarity: fair (蘋果和香蕉都是水果，那火車和輪船？)

畫鐘測驗：請她畫11:05分的鐘。可測多項。

JOMAC: judgment, orientation, memory, abstract, calculaiton

C.         Memories (recent, remote, and immediate): fair (給三樣東西互不相關如：綠色、快樂、電視機) 不能是白色因醫師穿白袍，過5分鐘再問她, phasia, spraxia, agnosia, executive functioning: fair

VII.    Insight and judgment

A.         Partial insight

B.         Judgment ( reasoning ability) tested only by hypothetical questions: fair

Physical Examination and Neurological Examination:

Impression:

Axis I

Axis II

Axis III

Axis IV

Axis V

Planning:

1.          Establishing rapport and collecting more data with patient and her family

2.          Monitoring psychotic symptoms and side effects

3.          Basic lab data establishment

4.          Principal medications

5.          Engaging to individual and group psychotherapy

6.          Psycho-education to the family and patient

7.          Psychological and OT assessment for the functional evaluation and occupational arrangement

8.          RT and milieu (社會文化環境) therapy