Competencies Flashcards
MSE
Appearance Behavior Psychomotor Eye contact Speech
Mood Affect Thought Process Thought Content Perceptual disturbances
Cognition Orientation Memory Attention/Concentration: Insight Judgement
MSE normal presentation
General appearance: -year-old ** who appears to be of stated age, casually dressed
Behavior: Cooperative with interview
Psychomotor: no psychomotor agitation or rigidity at the time of this assessment
Speech: Spontaneous speech with appropriate rate, volume, tone and cadence.
Mood: “”
Affect: Congruent with mood, **
Thought Process: Linear, goal directed
Thought Content: Denies suicidal or homicidal ideations, no apparent delusions noted
Perceptual disturbances: Denies auditory, visual, or other hallucinations
Cognition: grossly intact, not formally tested
Memory:grossly intact
Orientation: Alert and oriented to the surroundings and situations
Attention and Concentration: **
Insight: **
Judgment: ***
@FName@ is an age appearing young {GNDR:21867} {interviewed:22920} in {MM GENDER:15228} {location:21868}. @FName@ was awake, alert, and oriented to person place and time, and engaged in conversation {engagement:19882} with {eye contact:21869} eye contact. @Fname@ demonstrated appropriate grooming and hygiene and dressed {Attire:21870} . Mood was described as “ {mood:21871}” with {affect:19512} affect. Speech was {speech:19884}. Language was age appropriate based on ability to name objects. Thought form was {thought form:19513} appropriately to developmental age.Thought content was devoid of paranoid ideation or other delusions. There was no indication of response to internal stimuli and no such experience was endorsed. Cognition/fund of knowledge was estimated to be in the {cognition:19885} range {based:19514}. Memory was {intact:21872} as evidenced by {recall:21873} . Attention span and concentration were {descriptor:21874} based on the {ability:21875} to engage in conversation for an extended period of time without notable difficulty. Judgement and insight were deemed to be developmentally {appropriate/inappropriate:14153} based on the {ability:21875} to consider alternatives presented and demonstrate understanding and context of the symptoms. {suicidality:19515}. Gait was {descriptor:22919}; station was {descriptor:22919}.
Diagnostic Interview - Part 1
PART 1: Preface How old? When’s your birthday? How was your last birthday? What did you do? Who was there? What kind of cake? What kind of presents? What school do you go to? What grade? fav/least favorite subjects? fav/least fav teacher Who do you hate the most? What is your grade average in school? Outside of school What do you like to do after school? Music Physical activity Friends Do you have a best friend(s)? What do you guys like to do together? Nicotine Do any of your friends vape/smoke? Do any of your friends drink? Have they ever gotten drunk? Do any of your friends smoke cannabis? Other drugs? DO YOU? Sex Are any of your friends hooking up? Have you been in a relationship? Have you ever hooked up? Pets Who lives with you? How do you all get along? How do your parents manage misbehavior?
SUMMARIZE in humor
Strengths
Challenges
Family relationships
Diagnostic Interview - Part 2
Part 2
Ask kid: When your parents told you that you were coming here today, what did they tell you that you were coming for?
Ask parents: What would you like to accomplish with today’s visit? What is your goal/agenda?
mom/dad do you want to explain why they were brought here?
Diagnostic Interview - Part 3A
Part 3
Review Paper Work
- Paper work
- Past hx
-Intake form
-Rating scales
- Psychological reports
PMH
TBI “bonked in the head”
Seizures
Cardiac
Dev/birth
- PSH
- Allergies
- FMHDiagnostic Interview - Part 3B
Disorders - “some kids come to me because they are ____ does that sound like you?
ASD (<3)
ADHD (<7) - “were you hyper prior to age 7” → makes it difficult to parent / difficult to make friends → ODD / low self esteem
Anxiety → Avoidance → poor coping skills
Phobia
Separation - “do you have problems doing anything away from your parents, school, sleep, home alone?”
Generalized
Social - “don’t like parties, ordering things”
Trauma/Abuse - “ever have an experience you can’t get out of your head”
OCD
Depression - pervasive anhedonia, may have severe sadness, demoralization “problems that can’t get out of” → poor academics/poor social
SI
Have you ever wanted to go to sleep & not wake up?
Thought about doing something?
What would you do?
What would take you off the edge?
What keeps you going?
Mania - euphoria & expansive
Psychosis
“Boy it sounds like you have a hard life, if you could do something, anything for fun - what would you do?
Diagnostic Interview - Part 4
Part 4 - Formulation & Feedback 1. DX Since age \_\_\_ treated/untreated/poorly treated on \_\_\_ Status (accumulated impairment..)
2. Strengths/challenges (what makes it harder/easier to treat) - That impact presentation / ability to participate in tx Intellect Temperament / regulatory capacity Match to environment (school) Tx: 504/IEP
- Maladaptive behaviors (that will get in the way)
Tx:behavior strategies for child/parent - Life narrative
How patient thinks about themselves
prognosis
Tx: reframe personal narrative
Diagnostic interview part 1 list
Age
Birthday
School
Leisure
Friends / drugs
Family
