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Department of Psychiatry

Supplemental Materials

Appendix I: Data Base - Psychiatry

Sample format for oral or written case presentations

The goal of the psychiatric interview is to provide input to the team that other members will not be providing. The perspective should be medical/psychiatric. The following example is intended as a model. All the detail suggested may not be necessary in each case, but all of the main headings must be covered in each psychiatric database.

• IDENTIFYING DATA
  
  Provide brief description of patient including name, age, race, religious preference, marital status, employment status, current or most recent occupation, residence and nature of relationship to patient of those with whom he or she resides.
• CHIEF COMPLAINT
  
  State the reason for the present admission including whenever possible a direct quotation of the patient's thoughts as to why admission was necessary.
• HISTORY OF PRESENT ILLNESS
  
  Include a detailed description of the history pertinent to the current episode of illness.
• PSYCHIATRIC HISTORY
• PAST PERSONAL AND SOCIAL HISTORY
• PAST MEDICAL/SURGICAL HISTORY
• CURRENT MEDICAL STATUS
  
  Current medications, results of physical exam and laboratory tests, drug allergies (list medications and its adverse effects)
• MENTAL STATUS
1. General appearance: gestures, mannerisms, posture, hygiene, grooming, etc.
2. Speech: rate, tone, volume, hesitation, etc.
3. Form of thought: blocking pressure/retardation, nature of associations and thought patterns
4. Thought content:
   
   dominant themes and topics, preoccupations
   hallucinations (auditory/visual)
   delusions (nature)
   homicidal/suicidal ideation
5. Affect: quantity, range, relations to content (appropriate or inappropriate) etc.
6. Intellectual abilities:
   
   orientation
   memory (recent and remote)
   estimate of intelligence range
   fund of knowledge
   calculations, abstractions (e.g. proverbs)
7. Insight and judgement
1. DIAGNOSIS
   
   Diagnosis should be made using DSMIV categories and criteria. Diagnoses should routinely be considered for Axis I, II and III. For your final written presentation, include all five axes as relevant.
   
   
   Axis I: Major clinical syndrome or condition that is the focus of attention or treatment.
   
   Axis II: Personality Disorders
   
   An Axis II diagnosis of a personality disorder should be made when there are enduring patterns of perceiving, relating to and thinking about the environment and oneself which are exhibited in a wide range of important social and personal contexts. These patterns are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress.
   
   Axis III: General medical conditions
2. ASSESSMENT
   
   Give a short paragraph, which provides an overall picture of the patient and his current problem. For your final written presentation, include a lengthy assessment that includes formulations according to all relevant theoretical frameworks (biopsychosocial, behavioral, psychoanalytic, family systems, descriptive, etc.), with appropriate literature references.
• ESTIMATED LENGTH OF STAY
• PROGNOSIS
• PLAN

This discussion of recommended interventions should follow from the diagnosis and assessment.

Appendix II: Interview Process

A. INITIATING INTERVIEW - The manner in which the interviewer greets the patient and his ability to cope with the patient's anxiety about the interview, and the method by which he sets the physical arrangement for the interview.

5. Patient given positive acceptance; purpose of interview explained and concerns of patient pursued, disruptive problems corrected.

4. Warm greeting, procedure explained by not purpose, cursory attempt to query patient about concern, cursory attention to physical conditions.

3. Greeting in tone and expression acceptable, but no explanation of procedure, no attempt to query patient about concern, no attention to physical conditions.

2. Brief recognition of patient with no attempt to put patient at ease and/or physical situation not conducive to interview.

1. No attempt to set up interview, launches directly into content.

B. EASE OF INTERVIEWER - The affect and attitude of the interviewer and whether personality characteristics enhance or interfere with the total flow of the interview.

5. Interviewer comfortable and confident, demonstrates empathy and sympathy, makes supportive comments.

4. Comfortable, well-controlled but indicates by verbal or nonverbal mannerism that there is discomfort.

3. No obvious discomfort, but allows negative personal attitudes to merge at times during the interview.

2. Moderately uncomfortable, gives inappropriate or unrealistic reassurance, allows affect and mannerism to interfere with the interview, transmits excessive information to the patient.

1. Definitely uncomfortable, interventions and mannerisms interfere with the conduct of the interview.

C. CONTROL OF PATIENT'S AFFECT - The ability of the interviewer to recognize and cope with the emotional qualities of the patient.

5. Demonstrates awareness of patient's affects by interventions which tend to put patient at ease.

4. Demonstrates awareness of patient's affects by interventions, but interventions do not always facilitate the interview.

3. Demonstrates awareness of patient's affect by interventions, but interventions create partial discomfort.

2. Does not demonstrate an awareness of patient's affect.

1. Interviewer's discomfort creates untoward affect in patient to the extent there is interference with parts of the interview.

D. INTERVIEW CONTINUITY - Interviewer guides flow of interview to cover the important areas necessary for the purpose of the interview.

5. Control of flow of information, effective utilization of time, moves from areas smoothly with transitional comments, follow up on affect and observation.

4. Maintains control of interview and his role, but flow if interview uneven, inconsistent follow-up on affects and observations.

3. Maintains control of interview, but is less effective in gathering data.

2. Loses control of interview or finds it necessary to over-control during the major part of the interview.

1. Loses control or rigidly controls to the point of ineffectiveness.

E. SKILL AND TECHNIQUE OF INTERVIEW - Interviewer's skill and ability in using techniques of interview and gathering data from patients, such as facilitation, clarification, use of silence, confrontation, and open-ended questioning, etc., uses vocabulary appropriate to patient's culture and education, utilizes appropriate questions for information desired.

F. TERMINATION - The skill and tact through which the interview is terminated and the patient's anxiety and expectations are met.

5. Interviewer takes full responsibility for terminating interview and clarifies the circumstances.

4. Recognition of the end of the interview and some attempt to assist patient.

3. Recognition of end of the interview, but no further steps taken.

2. Interviewer takes little or no responsibility for termination.

1. Interview ends by attrition and patient is ignored.

Appendix III: Faculty

The faculty of the Department of Psychiatry are:

• Thomas Newmark, MD – Chief
• Jeff Dunn , MD – Clerkship Director, Director, Residency Training and
• Head, Division of Consultation/Liaison
• Pamela Szeeley, MD – Head, Division of Community Psychiatry
• Ruksana Iftekhar, MD – Head, Division of Ambulatory Care
• Rao Gogineni, MD – Head, Division of Child and Adolescent Psychiatry
• Paul Topol , MD – Head, Inpatient Unit
• Teresa Humaran, MD – Head, Division of Geriatric Psychiatry
• David Bogacki, Ph. D – Head, Division of Psychology
• Dorothy Brocco , MSW, LCSW – Therapist, Outpatient Services
• Clerkship Coordinator – Viktoria Rile

For more information, contact Viktoria Rile, Clerkship Coord. at 856-757-7853

© 2004 ROBERT WOOD JOHNSON MEDICAL SCHOOL, ALL RIGHTS RESERVED, 675 HOES LANE, PISCATAWAY, NJ 08854