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Name
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Lina Evans
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DOB
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26/04/1974 (42 years)
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Occupation
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Unemployed
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History
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I feel I am wasting the
doctor's time coming in with tiredness. I am apologetic and ask if perhaps I
should just take sleeping tablets. I have been sleeping poorly for 2 months,
waking up several hours before I usually would wake up. Throughout the day I
feel tired and if directly asked, I admit to feeling low. I have stopped
doing the things I enjoy such as going out with my friends and the gardening.
I do not work, having been made redundant from being a payroll clerk 2 years
back. This has led to my partner having to work harder and longer as an
accountant which has increased the stress in our relationship so much that we
sleep separately. Admits to poor libido if directly asked. Feels hopeless
about the future and guilty for being made redundant. Spends most days
watching TV and caring for her father who lives together with her. Denies all
other symptoms and denies risk of self harm or suicide.
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Past Medical History
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Acid reflux. High blood
cholesterol. No previous psychiatric issues
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Drug History
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Omeprazole and
Atorvastatin. No allergies
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Family History
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Mother committed
suicide during post natal depression. Father has had a stroke 3 years ago and
requires some help with daily activities.
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Social History
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Lives with father and
is one of multiple carers for him. He has long term left sided paralysis. Has
good social support with close group of friends. Drinks on the weekends with
friends usually, but hasn't been up to going for the last month.
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Introduces self
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0
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1
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Confirms name &
age of patient
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0
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1
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Explains reason for
consultation & builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes duration of
symptoms
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0
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1
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Establishes
triggers/stressors/life events
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0
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1
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Asks for core symptoms:
low mood, anergia, anhedonia
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0
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1
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2
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Asks for biological
symptoms: sleep, loss of libido, appetite
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0
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1
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Asks for cognitive
symptoms: feeling hopeless, worthless, helpless, poor memory/concentration
and guilty
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0
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1
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2
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Asks if patient has
ever felt elated
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0
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1
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Asks if experiencing
hallucinations (visual/auditory/olfactory)
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0
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1
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Looks for any delusions
and tests their conviction
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0
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1
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Asks about risk of
suicide/self harm
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0
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1
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Establishes if anything
could change their risk
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0
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1
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Establishes if patient
is neglecting oneself or others
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0
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1
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Explores impact of
symptoms on occupation
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0
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1
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Explores impact of
symptoms on home and social life
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0
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1
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Explores the level of
support
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0
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1
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Identifies if the
patient has insight and willingness to accept treatment
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0
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1
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2
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Looks for substance
misuse
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0
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1
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Asks about previous
medical & psychiatric history
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0
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1
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Asks whether patient is
taking regular medication or has allergies
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0
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1
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Asks about family
history of psychiatric or medical disorders
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0
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1
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Explores and responds
to ideas
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0
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1
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Explores and responds
to concerns
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0
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1
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Explores and responds
to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to
patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable
differential diagnosis (depression, mixed anxiety and depressive disorder, hypothyroidism)
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0
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1
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Summarises back to
patient
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0
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1
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Thanks patient
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0
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1
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