Psychiatric patient note for CS

[Jamaicacarioca]

Can anyone tell me how to write up the physical exam for a psychiatric patient with hallucinations.
In the kaplan book it says you should just write
Psychiatric exam:
Appearance,Suicidal/harmful intentions,speech,mood,thought process,hallucination.

in the first aid book it says you should just write up a normal physical exam.

---

Members don't see this ad.

 

[Saluki]

Can anyone tell me how to write up the physical exam for a psychiatric patient with hallucinations.
In the kaplan book it says you should just write
Psychiatric exam:
Appearance,Suicidal/harmful intentions,speech,mood,thought process,hallucination.

in the first aid book it says you should just write up a normal physical exam.

I would write it up like a normal exam like you would if you are an ER resident or family practiioner seeing the patient. Even if the complaint coming into the ER seems psychiatric, it could be a medical issue. For hallucinations, delirium, alcohol withdrawal, PCP or LSD use, lupus, etc.
You can add things like "rapid speech" or "pacing" into the general appearance part of your exam and add things like "alert and oriented to person, place and time" under a separate mental status line or into your neurologic exam depending on your preference.
In a non psychiatric note, the suicidal ideation should probably just be in the history.

 

[drdil]

I would go with the normal physical exam as in FA............
BTW how and where do i post if I want a study partner in houston. Taking exam within the next 15 days!!!!!!