Describe your patient so well that a reader would be able to recognize him from your description alone.

Content to utilize to summarize learning reflection: All of this info is to help you compile robust 1 page response of reflective learning. MENTAL STATUS EXAMINATION In writing up or dictating the mental status section of your diagnostic evaluation, temporarily shed your clinician’s mantle and become a creative writer. Describe your patient so well that a reader would be able to recognize him from your description alone. Compare the following two descriptions of the same patient: The patient was a 32-year-old man who was tired but cooperative with the interview. He was disheveled. Eye contact was good. Mood and affect were angry and irritable. The patient was interviewed in a medical bay of the emergency room. He was lying on his back on a gurney in four-point restraints, wearing a hospital gown. He had received 5 mg of haloperidol (Haldol) intramuscularly shortly before the interview. As I walked in, he lifted his head and looked at me intensely, saying, “Will you get me the hell out of these shackles?” I assured him that I would do so if he posed no danger to himself or others. He was resigned and cooperative from that point on. The second version gives a more vivid sense of the patient’s mental status. Yes, he is angry and irritable, but this is in reaction to something in his environment. Furthermore, he’s able to modulate his affect in response to the interviewer’s statement, indicating a degree of control over his emotional state not communicated by the first summary. The “disheveled” of the first write-up might imply the self-neglect characteristic of schizophrenia, but in fact it’s hard to look anything but disheveled when you’re in a gurney with your limbs restrained. That said, professional jargon does have its place in the write-up. This is especially true in the description of psychotic thought process (TP) and thought content (TC). Words and phrases such as tangentiality, looseness of associations, and ideas of reference are technical terms with meanings that are understood throughout the mental health field, and they should be used when appropriate. Table 34.1 lists some common jargon-containing statements and some fresher alternatives. Table34.1 Alternatives to Jargon Your MSE can follow the format outlined in Chapter 21 (recall the mnemonic: All Borderline Subjects Are Tough, Troubled Characters). A good strategy is to limit jargon to those aspects of the MSE that are normal and to use more descriptive language for those parts of the examination that are directly relevant to the eventual diagnosis. This was a well-groomed, pleasant-appearing woman, dressed in a professional suit and smelling strongly of perfume. She presented herself as serious and engaged. Her body was tense; she spoke rapidly and articulately as she related her psychiatric history. She seemed quite anxious, with her hands clenched around her billfold and her feet tapping the floor. Her stated mood was “I’m just barely holding on,” and “I’m scared of having a panic attack all the time.” Her TP was coherent in content and without hallucinations or delusions, but with some excessive rumination on the theme of getting “just the right medicine.” She denied SI. On cognitive screen, concentration and memory were normal. Writing Up the Results of the Interview I’ve had a long and stormy relationship with the dreaded write-up. During medical school, the requirement of a novel-length write-up was a welcome reprieve from the stresses of rounding on patients and making oral presentations. In residency, I became annoyed with the write-up, which seemed a pesky intrusion into the limited time I had to spend with patients. At the end of a long day, I would sit down heavily at the Dictaphone (remember those?) and try to gather my thoughts, hoping that the resulting transcription would be coherent. It wasn’t until I had been in clinical practice for a few years that I came to terms with the write-up. Having come full circle, I’m back to (sort of) liking it, viewing it as a welcome few minutes of quiet thought and synthesis between patient appointments. I hope this chapter helps you to work through some of the more painful moments in your own relationship with the write-up. I outline some formats for you to choose among, and I provide some tips to help you streamline the process. Every write-up represents a balancing act among three objectives: Thoroughness Time efficiency Readability The ideal write-up incorporates all three objectives. It is thorough enough to document the basis for a diagnosis and treatment plan; it does not require so much time that it would be unfeasible for a busy clinician to produce; and it is not so lengthy as to provoke sighs from equally busy colleagues who must read the write-up because of their involvement in the patient’s treatment. In general, a write-up should not take you more than 10 to 15 minutes to produce, whether you dictate it or write it yourself. It should not be longer than two or three typed pages if you really want colleagues to read it. If you use electronic health records (EHRs) for documentation, you may be constrained by the particular software you or your employer has chosen. At their worse, EHR write-ups become clicking fests through dozens of checkboxes defining different aspects of the mental status exam. I recommend that you use the free-text fields when possible, so that you can build up a narrative picture of your patient that will be more informative to you and others. IDENTIFYING DATA The identifying data should be a fairly long initial sentence that sets the stage for the entire evaluation. You want to not only identify who the patient is but also to locate her within the context of social and cultural norms. This includes age, sex, marital status, and source of referral at a minimum and may include other information such as occupation, living situation, and presence of other family. This is a 45-year-old, twice-married woman with two grown children, who is an accountant for her husband’s carpet cleaning business and who was referred by her primary care doctor because of increasing anxiety and the possibility that she is abusing anxiety and pain medication. or This is a 29-year-old, single, white man on psychiatric disability, living in a group home downtown, with a long history of paranoid schizophrenia, who was admitted to the hospital after group home staff members found him in the process of drinking a bottle of methyl alcohol in an apparent suicide attempt. CHIEF COMPLAINT The chief complaint should be a verbatim sentence of the patient’s, usually in response to your question as to the reason he is seeking help. My wife made me come here. There’s nothing wrong with me. My mother just died. I can’t deal with it. I just figured it was time to see a therapist to work out some issues. Each of these statements reflects a different sense of purpose and urgency for treatment, and consequently, this information is helpful in setting the stage for the report to follow. HISTORY OF PRESENT ILLNESS In Chapter 14, I describe two different definitions of the history of present illness (HPI), one referring to the history of the illness, which may begin years before the interview (history of syndrome approach), and the other referring more narrowly to events of the past few weeks (history of present crisis approach). Which definition to use is a matter of personal or institutional preference. Following are examples of both approaches. History of Syndrome Mr. M has a long history of bipolar disorder, beginning in his junior year of college. He was hospitalized for manic behavior, which included studying for days at a time to the point of exhaustion. In addition, he exhibited grandiose, disorganized behavior when he “occupied” the chancellor’s outer office and stated that he was the chancellor of the university. He was started on lithium at that point and did well for several years, until he had a series of hospitalizations in the early 1990s for depression and alcohol use after a divorce from his wife. His last hospitalization was 2 years ago for depression, and he has done fairly well since then, taking medications (venlafaxine [Effexor] and valproic acid [Depakote]) and going to regular therapy and medication appointments. History of Present Crisis Mr. M has a long history of bipolar disorder with several hospitalizations but had been doing fairly well for the past 2 years until about 2 weeks ago, when his girlfriend noticed a pattern of manic behavior, which began after a promotion to a new position at his company. He has slept an average of 3 hours a night because of a need to “prepare for his day,” he has been talking more rapidly than usual, and he has been making unrealistic plans to become the president of his company. He consented to this admission on the advice of his girlfriend and his outpatient caregivers. Reference Carlat, D. J. (2017). The psychiatric interview (4th ed.) Wolters Kluwer.