Psychiatry consults, as you'll see, are written largely like any other medical consult. The job of the consultant is to review the case thoroughly, summarize their understading thus far, offer diagnostic possibilites, and most importantly, give medical adivce to the physician requesting the consult.
Many psychiatry residents write "wishy-washy" consults, often without commiting to diagnoses or treatment options. Unless the case is substantially difficult or other unusual circumstances, make a diagnosis (if appropriate), and give solid treatment options. Check with your hospital to see if the consulting psychiatry resident will write the orders suggested from the consult. Our hospital, for example, wants all major orders to come from the primary medical team. In this sense, the consultant is just that, a consultant giving an opinion and advice.
The consult generally consists of the following:
1. Short HPI, rehashing the case events thus far.
"Mrs. X is a 32 year old single female who was admitted to the general medical floor for severe electrolyte imbalance secondary to what the patient describes as intractible vomiting. Psychiatry was consulted to evaluate the possibility of self-induced vomiting, and to recommend treatment options if warranted."
Then, go into your details of the psychiatric interview, using quotes for the patient's own words when appropriate.
2. Past medical history
3. Past surgical history
4. Family history
5. Social history, including substance use, living situation, alcohol use, IVDA, other drug use, detoxes, OTC meds, etc.
6. List medications, dosages.
7. List most recent labs, if appropriate, imaging results, and lab trends. Add vitals above this.
8. Mental status results
9. "Diagnostic Impression:"
Use the DSM-IV 5 axis system here, being sure to include all relevant medical issues on III.
10. Impression: Restate the initial question, then summarize briefly your thoughts and list, very clearly, your treatment suggestions, including medications, dosages, psychiatric followup and other plans. If the case warrants followup by the psych c/l team, indicate that psychiatry will follow the case, or that they can reconsult psychiatry if needed.
Keep in mind that most residents, interns, and attendings will only read the Diagnosis, impressions, and recommendations section of your consult. Make it good and make it clear. Don't be afraid to give basic science reasons for decisions you make. This is often appreciated, and gives the resident presenting the case on rounds an understanding as to why they should follow your suggestions. If you're not sure what to suggest, ask your resident or attending.
Good luck!
