Psychosis
HISTORY:
for
, , a plan, intent to act
, , a plan, intent to act
Recent stressors:
Impact on daily activities:
Other elements:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Occupation: risk of injury for self or others
Living situation:
Support system:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Neurologic:
- Mental status: , oriented in , speech
- Cranial nerves:
- Strength: upper extremities -R /5 , -L /5
lower extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L ,
lower extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
patellar -R , -L , achilles -R , -L , plantar -R , -L
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike ,
- Gait: , tandem walking , heel and toe walking
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , ,
- Urine drug screen
- Urinalysis
- CT scan of the head
- Psychoeducation about psychosis
-
-
- if depressive symptoms are present
- for acute agitation or severe anxiety
- Supportive therapy
- Cognitive behavioral therapy
- Psychiatric hold
- Admit to psychiatry unit
- Referral to psychiatrist
- Referral to psychologist
- Referral to social worker
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as confusion, memory loss, or changes in behavior or mood