Comprehensive Checklist for Systematic Approach to Patient Care

M

P

L

D

S

M

C

S

S

C

P

T

F

Medical Psychosocial Hx

Physical Exam

Labs

Depression Inventory 

Suicide Assessment 

MMSE 

CAGE 

Safety 

Support 

Community Resources

Patient Education 

Treatment/Referral 

Follow Up 

Complete medical and psychosocial history

Complete physical examination  

Appropriate labs and diagnostic tests

Depression inventory

Suicide assessment

Mini Mental Status Examination 

CAGE

Safety

Support System

Community resources

Patient Education

Treatment plan/referral

Follow-up

Hx

C

O

D

A

R

A

M

O

A

P

F

L

E

A

S

Chief complaint

Onset

Duration

Associated symptoms

Relieving factors

Agrevating factors

Meds

Other OTC/herbals

Allergies

PMHx

FHx

LMC

Effects on life

Anything else

Summary

10 Minute Counseling Sessions  

Protocol to determine context of visit

B Background

A Affect

T Trouble

H Handling

E Empathetic statement

“What is going on in your life?”

“How do you feel about that?”

“What troubles you the most about this?”

“How are you handling that?”

“That must be very difficult for you.”

Empathetic statements

• “That must be very difficult for you.”

• "This is a tough situation to be in"

• "Anybody would feel as you do"

• "Your reaction makes sense to me"

Depression  (5/9 for more than 2 weeks)

Depressed mood

Anhedonia

Weight or appetite change

Insomnia/Hypersomnia

Psychomotor agitation or retardation

Fatigue/Loss of energy

Worthlessness/guilt

Indecisive/decreased concentration

Recurrent thoughts of death

Suicide Assessment:

1. What is the extent of the patient's thinking and behavior related to suicide?

2. Does the patient demonstrate historical and sociodemographic risk factors fore completed suicide?

3. Does the patient meet criteria for a psychiatric disorder that has been associated with completed suicide?

Screening for Alcohol Dependence

Cut Down

          Ever felt you ought to cut down on your drinking?

Annoyed

          Have people annoyed you by criticizing your drinking?

Guilty

          Ever felt bad or guilty about your drinking?

Eye Opener

          Ever had an eye-opener to steady nerves in the AM?

Manic (3/7)

Self esteem/grandiose

Decreased sleep

Pressured Speech

Thoughts racing

Distractibility

Increased goal oriented activity

Leads to increased pleasurable activities with painful consequences

Hostile Patient

Show empathy

Reiterate treatment process

Ask what they would like - offer alternative

 (i.e. 2nd opinion, more testing, referral)

Education about situation

Suggest treatment options

Seductive Patient

Ask what patient wants & alternatives

Maintain boundaries (non-scolding way)

Education about what patient feels they need

Get Hx of problems, support system, activities

Offer Support

Hypochondriac/Somatizing

Offer support and empathy

Explain/educate about somatic symptoms and stress

Additional history - R/O depression/anxiety disorders/PTSD

Review Tests - reassure about positive aspects of physical exam and testing

Types of Elder Abuse 

Physical

The use of physical force 

Sexual

Non consensual sexual contact of any kind with an elderly person 

Emotional (Psychological)

Infliction of anguish, pain, or distress through verbal or nonverbal means 

Neglect

Refusal or failure to fulfill any part of a persons obligations or duties to an elder 

Abandonment

The desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder. 

Financial or material exploitation

The illegal or improper use of an elder's funds

Self-Neglect

The behavior of an elderly person that threatens his/her own health or safety

Diagnosing Anxiety (3 criteria):

Relaxation difficulties

Anxiety Disorder

Separation Anxiety

excessive anxiety about being separated from a major attachment figure

Panic Disorder

Discrete period of intense fear with 4 or more symptoms developing and peaking with 10 minutes

Symptoms: 

     palpitations

     choking 

     de-realization or depersonalization 

     sweating 

     chest pain 

     fear of losing control/going crazy 

     trembling/shaking

     nausea/GI distress

     paraesthesias 

     shortness of breath

     dizziness 

     fear of dying 

     chills or hot flushes

Generalized Anxiety Disorder (GAD) 

Excessive anxiety for 6 months or more 

3 of:

     restlessness/feeling on edge

     irritability 

     easily fatigued

     muscle tension

     trouble concentrating

     poor sleep

Early onset - before age 20

Post-Traumatic Stress Disorder (PTSD) 

Exposure to a traumatic event involving actual or threatened death or serious harm to self or others, AND reaction of fear, horror, or helplessness

Social Phobia

Excessive fear of social or performance situations, public humiliation

Obsessive-compulsive Disorder (OCD) 

Persistent, irrational thoughts or images (obsessions) and/or repetitive behaviors that the patient feels driven to perform to reduce anxiety 

Adjustment disorder with anxious mood

Anxiety due to  a medical condition

Psychotherapy - General Principles 

(This is from the role playing we did during the psychotherapy lecture)

Greeting Patient: Small Talk, graceful entry 

Active Listening: Body Language, eye contact, nodding, grunts, reflecting, paraphrasing, summarizing

Empathetic Comments

Validating in terms of normal functioning

Agreeing/Negotiating of problem areas

Asking the patient about next steps (How to feel better, do something, have more friends, mobilize support, get meds) 

Graceful ending of interview - transition to next appointment or referral

Four topics of clinical ethics in case analysis

MEDICAL INDICATIONS 

1. What is patient's medical problem?

history? diagnosis? prognosis? 

2. Is problem acute? chronic? critical? emergent? reversible? 

3. What are goals of treatment? 

4. What are probabilities of success?

5. What are plans in case of therapeutic failure? 

6. In sum, how can this patient be benefited

by medical and nursing care, and harm

avoided?

PATIENT PREFERENCES 

1. What has the patient expressed about  

preferences for treatment? 

2. Has patient been informed of benefits and risks, understood, and given consent? 

3. Is patient mentally capable and legally 

competent? What is evidence of incapacity? 

4. Has patient expressed prior preferences, e.g. Advance Directives? 

5. If incapacitated, who is appropriate surrogate? Is surrogate using appropriate standards? 

6. Is patient unwilling or unable to cooperate with medical treatment?  If so, why? 

7. In sum, is patient's right to choose being respected to extent possible in ethics and law?

QUALITY OF LIFE 

1.What are the prospects, with or without

treatment, for a return to patient's

normal life? 

2. Are there biases that might prejudice provider's evaluation of patient's quality of life? 

3. What physical, mental, and social deficits is patient likely to experience if treatment succeeds? 

4. Is patient's present or future condition such that continued life might be judged undesirable by them? 

5. Any plan and rationale to forego treatment? 

6. What plans for comfort and palliative care? 

CONTEXTUAL FEATURES 

1. Are there family issues that might influence treatment decisions? 

2. Are there provider (physicians and nurses) issues that might influence treatment decisions? 

3. Are there financial and economic factors?

4. Are there religious, cultural factors? 

5. Is there any justification to breach confidentiality? 

6. Are there problems of allocation of resources?

7. What are legal implications of treatment

decisions?

4 Moral Principle of Clinical Ethics 

    AUTONOMY 

    BENEFICENCE 

    NON-MALFEASANCE 

    FAIRNESS/JUSTICE

Consideration of the four topics plus the four principles define the ethical problem and should suggest a resolution.

Impairment- Organ 

Disability - Functional limitation at the level of person  

Limitations in task performance 

Handicap - At the level of the interaction between the person and the environment (societal view) 

       Example - HIV Diagnosis (without disease) creates a significant handicap without any disability

Interview the patient as an expert in their own body

Assess ADLs

Different Kinds of Psychotherapy 

Supportive (e.g. Chronic situations, illness, stresses)

Investigative (Is there a problem? Is it Normal?)

Problem-Solving 

Resolution of Acute Issue (Grief)

Investigation/Resolution of Longstanding Issue 

Personality Change:

     Accept Vs. Change

     Reduce Harmful Behaviors

     Reinforce Positive Behaviors

     Limits on Contact for Positive Reinforcement

Prepare for Crisis (Education before surgery) 

Education for Health; Emotional Reactions 

Substance Use Reduction 

Behavioral Intervention

     A = Antecedents 

     B = Behavior 

     C = Consequences

Model of Sex Therapy

PLISSIT

Permission

Limited

Information

Specific

Instructions

Intensive

Therapy

Depression Screening

Sleep decreased (Insomnia with 2-4 am awakening)
Interest decreased in activities (anhedonia)
Guilt or worthlessness (Not a major criteria)

Energy decreased

Concentration difficulties
Appetite disturbance or weight loss
Psychomotor retardation/agitation
Suicidal thoughts

Depression Screening -

Zung Depression Scale

Beck Depression Inventory

Depression Tx:

Screen 

R/O Substance Abuse

R/O Organic Causes

Diagnosis

Consider Psychotherapy

Pharmacotherapy

Refer if Indicated 

Appropriate Labs:

TSH

CBC

LFTs

CMP

RPR

Cluster A

Personality Disorders

Paranoid Personality Disorder

SUSPECT (4 criteria)

S: Spouse fidelity suspected
U: Unforgiving (bears grudges)
S: Suspicious of others
P: Perceives attacks (and reacts quickly)
E: "Enemy or friend" (suspects associates, friends)
C: Confiding in others feared
T: Threats perceived in benign events

Shizoid Personality Disorder

DISTANT (4 criteria)

D: Detached (or flattened) affect
I: Indifferent to criticism and praise
S: Sexual experiences of little interest
T: Tasks (activities) done solitarily
A: Absence of close friends
N: Neither desires nor enjoys close relations
T: Takes pleasure in few activities

Schizotypal Personality Disorder

ME PECULIAR (5 criteria)

M: Magical thinking or odd beliefs
E: Experiences unusual perceptions

P: Paranoid ideation
E: Eccentric behavior or appearance
C: Constricted (or inappropriate) affect
U: Unusual (odd) thinking and speech
L: Lacks close friends
I: Ideas of reference
A: Anxiety in social situations
R: Rule out psychotic disorders and pervasive developmental disorder

Cluster B

Dramatic, Erratic Group

Antisocial Personality Disorder

CORRUPT (3 criteria)

C- Conformity to law lacking 

O- Obligations Ignored 

R- Reckless disregard of safety for self or others 

R- Remorse lacking 

U- Underhanded (deceitful, lies, cons)

P- Planning Insufficient (Impulsive) 

T- Temper (Irritable and aggressive) 

Borderline Personality Disorder

AM SUICIDE (5 criteria)

A- Abandonment 

M- Mood instability

S- Suicidal or self mutilating behavior

U- Unstable and intense relationships

I- Impulsivity ( > 2 self damaging areas)

C- Control of Anger

I- Identity Disturbance 

D- Dissociative (or paranoid) symptoms

E- Emptiness (chronic feelings of)

Histrionic Personality Disorder

PRAISE ME (5 criteria)

P  -  Provocative behavior (or seductive)

R - Relationships (more than they are) 

A - Attention (uncomfortable when not center)

I - Influenced Easily 

S - Style of speech (impressionistic, lacks det.)

E - Emotions (rapidly shifting and shallow)

M - Made Up (physical appearance to draw attention to self) 

E - Emotions exaggerated (theatrical) 

Narcissistic Personality Disorder

SPECIAL (5 criteria)

S - Special (believes is special or unique)

P - Preoccupied with fantasies (of unlimited success

E - Entitlement power, beauty, etc…)

C - Conceited (grandiose sense of self importance)

I - Interpersonal Exploitation 

A - Arrogant (haughty) 

L - Lacks empathy

Cluster C

Anxious, Fearful Group

Avoidant Personality Disorder

CRINGES (4 criteria)

C - Certainty (of being liked before willing to get involved with others)

R - Rejection (or criticism) preoccupies ones thoughts in social situations

I - Intimate relationships (restraint in intimate relationships due to fear of being shamed)

N - New interpersonal relationships (is inhibited in)

G- Gets around occupational activity (involving significant interpersonal contact)

E - Embarrassment (potential) prevents new activity or taking personal risks

S - Self viewed as unappealing, inept, or inferior

Dependent Personality Disorder

RELIANCE (5 criteria)

R- Reassurance required for decisions

E - Expressing disagreement difficult ( due to fear of loss of support or approval)

L - Life responsibilities (need to have these assumed by others)

I - Initiating projects difficult (due to lack of self-confidence)

A - Alone ( feels helpless and discomfort when alone)

N - Nurturance (goes to excessive lengths to obtain nurturance and support)

C - Companionship (another relationship) sought urgently when close relationship ends

E - Exaggerated fears of being left to care for self

Obsessive Compulsive Personality Disorder

LAW FIRMS (4 criteria)

L - Loses point of activity (due to preoccupation with detail)

A - Ability to complete tasks (compromised by perfectionism)

W - Worthless objects (unable to discard)

F - Friendships (and leisure activities) excluded (due to a preoccupation with work) 

I - Inflexible, scrupulous, over conscientious (on ethics, values, or morality, not accounted for by religion or culture)

R - Reluctant to delegate (unless others submit to exact guidelines)

M - Misery (toward self and others)

S - Stubbornness (and rigidity)