Extension for Community Healthcare Outcomes

Integrated Addictions & PsychiatryClinic

Patient Case Presentation

Date:______Presenter: ______ECHO id: ______DOB:______

Gender: M___ F____ New Case:______Follow-up: ______

PLEASE STATE YOUR QUESTION FOR THE ECHO IAP NETWORK:

⃝ Help with diagnosis

⃝ Help with medications

⃝ Help with non-medication treatment

Symptoms

Depression:
Insomnia/hypersomnia
Diminished Interest
Worthlessness/Guilt
Loss of energy
Diminished concentration
Significant weight loss
Psychomotor agitation/retardation
Suicidal ideation/thoughts of death
DURATION: / Mania:
Distractibility
Indiscretion (dangerous activities)
Grandiosity
Flight of ideas
Activity Increase
decreased need for Sleep
Talkativeness
DURATION: / Anxiety:
Trauma
Hypervigilance
Increased Startle
Avoidance
Negative Cognitions
Excessive Worry
Panic Attacks
Obsessions
Compulsions / Psychosis:
Delusions
Hallucinations
Auditory/Visual/Tactile
Disorganized behavior
Other:

Screening/Assessment Tool Scores (list any that apply):

Extension for Community Healthcare Outcomes

PHQ-9:

Level 2 Depression:

GAD-7:

Level 2 Anxiety:

Severity of Posttraumatic Stress Symptoms:

Severity Measure for Social Anxiety Disorder:

Severity Measure for Panic Disorder:

Level 2 Mania:

Level 2 repetitive Thoughts and Behaviors:

Level 2 Sleep Disturbance:

Clinician-Rated Dimensions of Psychosis Symptom Severity:

Other:

Extension for Community Healthcare Outcomes

Proposed Diagnoses:

1.

2.

3.

4.

Psych HX:

Hospital admission:(When/indication):

Meds tried in past:

Antidepressants / Antipsychotics / Anxiolytics / Mood Stabilizers / Others

Non-pharmacological Interventions Tried:

TRIED? / HELPFUL?
Community Resources / Y/N / Y/N
Community Reinforcement Approach / Y/N / Y/N
Seeking Safety / Y/N / Y/N
Motivational Interviewing / Y/N / Y/N
Behavioral Activation / Y/N / Y/N
Relaxation Strategies / Y/N / Y/N
Interoceptive Exposure Treatment / Y/N / Y/N
Anger Management / Y/N / Y/N
Mindfullness / Y/N / Y/N
Other: / Y/N / Y/N

History of:

Suicide attempt: Y/N If yes, date of last attempt:

Non-suicidal Self-Injurious Behaviors: Y/N If yes, date of last NSSIBs:

Homicide attempt: Y/N

Extension for Community Healthcare Outcomes

Current Medications: (Attach a med list if possible)

1.

2.

3.

4.

Medical Comorbidities:

1.

2.

3.

4.

Extension for Community Healthcare Outcomes

PDMP checked: Yes______No ______Pertinent Findings: ______

Substance Use History:

Quantity / Frequency / Last Use / Route
Caffeine
Nicotine
Alcohol
Methamphetamine
MDMA
Heroin
Opiates
Hallucinogens
Inhalants
Benzodiazepines
OTHER:

History of substance use disorder treatment:

Substance Abuse counseling: Past: Y/N Present: Y/N

Inpatient Substance Abuse Treatment: Y/N

12-steps/Mutual Support Groups: Past: Y/N Present: Y/N

LABS

TSH:
UDM:
CBC:
CMP: / Drug levels:
Hep C:
HIV:
LFTs:
Other:

Extension for Community Healthcare Outcomes

Family Psychiatric History:

1.

2.

3.

4.

Social History:

Education level:

History of abuse/neglect/violence:

Employed:

Partnered:

Legal involvement:

Housing: homeless/secure/transient

Access to guns: Y/N

Exercise: none/scant/regularly

Hobbies:

Race/ethnicity:

Sexual Orientation:

Extension for Community Healthcare Outcomes

Goals for treatment:

1.

2.

3.

4.

Proposed Treatment Plan:

1.

2.

3.

4.