Integrated Addictions & Psychiatry Clinic Patient Case Presentation Date:_____________ Presenter: ________________ ECHO id: _______________ DOB:_______________ Gender: M___ F____ New Case:__________ Follow-up: ______________ PLEASE STATE YOUR QUESTION FOR THE ECHO IAP NETWORK: ⃝ Help with diagnosis ⃝ Help with medications ⃝ Help with non-medication treatment Symptoms Depression: Mania: Anxiety: Psychosis: Insomnia/hypersomnia Distractibility Trauma Delusions Diminished Interest Indiscretion Hypervigilance Hallucinations (dangerous Worthlessness/Guilt Increased Startle Auditory/Visual/Tactile activities) Loss of energy Avoidance Disorganized behavior Grandiosity Diminished Negative Cognitions Flight of ideas concentration Excessive Worry Activity Increase Significant weight loss Panic Attacks decreased need Psychomotor Obsessions for Sleep agitation/retardation Compulsions Talkativeness Suicidal ideation/thoughts of death DURATION: DURATION: Other: Screening/Assessment Tool Scores (list any that apply): PHQ-9: Severity of Severity Measure Severity Measure Posttraumatic for Social Anxiety for Panic Level 2 Stress Symptoms: Disorder: Disorder: Depression: Level 2 Mania: GAD-7: Level 2 Anxiety:
Integrated Addictions & Psychiatry Clinic Patient Case Presentation Date:_____________ Presenter: ________________ ECHO id: _______________ DOB:_______________ Gender: M___ F____ New Case:__________ Follow-up: ______________ PLEASE STATE YOUR QUESTION FOR THE ECHO IAP NETWORK: ⃝ Help with diagnosis ⃝ Help with medications ⃝ Help with non-medication treatment Symptoms Depression: Insomnia/hypersomnia Diminished Interest Worthlessness/Guilt Loss of energy Diminished concentration Significant weight loss Psychomotor agitation/retardation Suicidal ideation/thoughts of death DURATION: Mania: Distractibility Indiscretion (dangerous activities) Grandiosity Flight of ideas Activity Increase decreased need for Sleep Talkativeness DURATION: Anxiety: Trauma Hypervigilance Increased Startle Avoidance Negative Cognitions Excessive Worry Panic Attacks Obsessions Compulsions Psychosis: Delusions Hallucinations Auditory/Visual/Tactile Disorganized behavior Other: Screening/Assessment Tool Scores (list any that apply): PHQ-9: Level 2 Depression: GAD-7: Level 2 Anxiety: Severity of Posttraumatic Stress Symptoms: Severity Measure for Social Anxiety Disorder: Severity Measure for Panic Disorder: Level 2 Mania:
IAP_CASE_PRESENTATION_TOOL_ACCESS_2015_9.docx