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Name
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Michael Richardson
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DOB
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29/03/1985 (31 years)
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Occupation
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Unemployed
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History
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My husband forced me to
come see you as he thinks I can be fixed. That's not possible as there's no
hope for me. For the last 3 months, I have known there's no point of living because
I have nothing going for me. If directly asked, 3 months ago my best friend
committed suicide. I sleep over 12 hours a day and wish I could sleep forever
as that's the only time I get any peace. There's been ghosts hanging from the
tree and they tell me that I will be joining them soon. I can feel that I am
rotting inside and I can smell it too! My husband has said I am stupid and
crazy, so I can't tell him what's going on. I only eat when he forces me and
haven't been out of the house for weeks apart from today. I have planned to
commit suicide during the weekend and ask the doctor if they know the easiest
way to go. I have made no concrete plans yet. I deny all other symptoms.
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Past Medical History
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Asthma. Previously
severely bullied as a child and considered suicide. Self harmed previously by
cutting wrist but recovered from that with talking therapy.
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Drug History
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Salbutamol and steroid
inhaler. Stopped taking them as there's no point. No allergies
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Family History
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Family history of
asthma and hayfever. Uncle who went crazy but nobody talks about him.
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Social History
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Lives with husband and
daughter. Husband has been looking after daughter as I am unable to. I do not
drink or smoke. I do not have any friends to go out with or any support
network.
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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 (psychotic depression, psychosis secondary to psychiatric or drug cause, schizoaffective disorder)
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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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