Albers, Hahn, Reist - Psychiatry - Current Clinical...

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Unformatted text preview: Current Clinical Strategies Psychiatry 2003-2004 Edition Rhoda K Hahn, MD Clinical Professor DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine Lawrence J. Albers, MD Assistant Clinical Professor DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine Christopher Reist, MD Vice Chairman DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine Current Clinical Strategies Publishing www.ccspublishing.com/ccs Digital Book and Updates Purchasers of this book can download the digital book and updates via the Internet at www.ccspublishing.com/ccs. Copyright ©2003-2004 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced, photocopied or stored in an information retrieval network without the permission of the publisher. No warranty for errors or omissions exists, expressed or implied. Readers are advised to consult the drug package insert and other references before using any therapeutic agent. Current Clinical Strategies is a registered trademark of Current Clinical Strategies Publishing. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653-7011 Phone: 800-331-8227 Internet: www.ccspublishing.com/ccs E-mail: info@ccspublishing.com Printed in USA ISBN 1-929622-30-9 Assessment and Evaluation Clinical Evaluation of the Psychiatric Patient I. Psychiatric History A. Identifying information. Age, sex, marital status, race, referral source. B. Chief complaint (CC). Reason for consultation; the reason is usually a direct quote from the patient. C. History of present illness (HPI) 1. Current symptoms: date of onset, duration and course of symptoms. 2. Previous psychiatric symptoms and treatment. 3. Recent psychosocial stressors: stressful life events that may have contributed to the patient's current presentation. 4. Reason the patient is presenting now. 5. This section provides evidence that supports or rules out relevant diagnoses. Therefore, documenting the absence of pertinentsymptoms is also important. 6. Historical evidence in this section should be relevant to the current presentation. D. Past psychiatric history 1. Previous and current psychiatric diagnoses. 2. History of psychiatric treatment, including outpatient and inpatient treatment. 3. History of psychotropic medication use. 4. History of suicide attempts and potential lethality. E. Past medical history 1. Current and/or previous medical problems. 2. Type oftreatment,includingprescription, over-the-counter medications, home remedies. F. Family history. Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse....
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Albers, Hahn, Reist - Psychiatry - Current Clinical...

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