PGH Form No P-450002

upmed2010.bevho

University of the Philippines Manila The Health Sciences Center DEPARTMENT OF PSYCHIATRY AND EHA!IORAL MEDICINE Taft Avenue, Manila PHIC Accredited Health Care Provider

PHILIPPINE GENERAL HOSPITAL

THIS IS A 2 PA!" #"$"##A% $&#M' P%"AS" $I%% UP A%% (%A)*S +T& (" ACC&MP%ISH", I) 2 C&PI"S-'

P"e#$e %&'( #pp)op)&#%e bo*. . / "0er1ency +has to 2e seen 3ithin the hour. / #outine + to 2e seen 3ithin 24 hours)ote5 $or patients 3ho already have dischar1e plans, referrals 0ust 2e dropped at least 2 days prior to dischar1e for a thorou1h psychiatric evaluation'

Patient6s Surna0e5 ,ate Ad0itted5 77777777 ,ate referred to Psychiatry5 Patient location5 8ard 9 Unit5 $or0 filled 2y5 #eferrin1 Physician5 Contact )o' of #eferrin1 M,5

(ed5
(printed name and signature)

CONS+LTATION,LIAISON REFERRAL FORM

Patient6s )a0e +Print-5
Last First MI

Case )u02er5 Address5

A1e5

Se:5

MSS Classification5 Clinical I0pression +Pri0ary 8or;in1 I0pression-5

Marital Status5 Tel )o'5 &ccupation5

Re#$o-$ .o) Re.e))&-/ %o P$0'h&#%)0 1P"e#$e %&'( bo*e$23 I h#ve -o%ed $ome 'h#-/e$ &- m0 p#%&e-%4$ MSE 5h&'h &-'"ude$3 . / Speech and lan1ua1e pro2le0s . / Inattention . / A1itation and restlessness . / A2nor0al, increased, or decreased 2ody 0ove0ents . / ,epressed 9 e:pansive 9 irrita2le 0ood . / A2nor0al ran1e, intensity, and appropriateness of affect . / Irrelevance of thou1ht process . / Illusions, hallucinations, delusions . / Suicidal ideations 9 intent 9 atte0pts< self har0 . / Confusional states or sensorial chan1es . / ,isorientation . / Me0ory i0pair0ents . / Poor =ud10ent and insi1ht F)om m0 p)e"&m&-#)0 &-%e)v&e56 I h#ve e"&'&%ed # h&$%o)0 o.3 . / previous psychiatric illness . / alcoholis0, prohi2ited dru1 9 su2stance use 9 a2use . / 2ehavior that deviates fro0 pre0or2id levels . / decline in social 9 occupational functionin1 in the past year . / i0pair0ent in fa0ily relations, or interpersonal relationships 3ith si1nificant others M0 p#%&e-% e*h&b&%ed $ome beh#v&o)$ %h#% h#ve #..e'%ed h&$ .u-'%&o- 5&%h&- %he ho$p&%#" $e%%&-/ %h#% &-'"ude$3 . / refusal or nonco0pliance to treat0ent . / e:pressed issues related to death and dyin1 . / need for co0petency evaluation +to secure

PGH Form No P-450002 rev02.09 upmed2010

consent. / e:pressed issues re1ardin1 pre9post operative copin1 . / pro2le0s 3ith staff . / others +please specify-5 77777777777777777777
RIEF

HISTORY OF THE A O!E PRO LEM

MEDICATIONS ON OARD (generic name and dosage) Steroids

THIS PSYCHIATRY REFERRAL IS DISCLOSED TO3 a- PATI")T . / yes . / no If not, please state 3hy5 2- $AMI%? . / yes . / no If not, please state 3hy5 DO NOT 8RITE ELO8 +to 2e filled 2y Psych #IC-

,ate of &nset5 Manner of &nset5 . / sudden . / 1radual &ther associated sy0pto0s5 . / inso0nia . / lac; of appetite "ffects on function in hospital5 . / ne1lects 1roo0in1, eats poorly, etc' . / poor co0pliance 3ith treat0ent . / ne1ativistic to3ards staff . / disruptive in 3ard< to other patients
RIEF MEDICAL HISTORY 1REASON FOR C+RRENT ADMISSION2 (you may attach patients clinical abstract)

Anti asth0a ,iuretics Anti hypertensives Anti T( &thers5

#esident in char1e5 ,ate #eceived5 ,ate $irst Seen5 LATEST LA ORATORY FINDINGS A:is I C(C5 A:is II Ti0e5 Ti0e5

Si1nificant P" 9 )" findin1s5

$(S9#(S5 *5 (U)5 AST5 Urinalysis5

)a5 Creatinine5 Al2u0in5 A%T5

A:is III

A:is I@ A:is @

Urine MAP +>uanti9>uali-5 "C!5 MENTAL STAT+S E7AMINATION A(!5 Cranial CT scan5 ""!5 %u02ar tap5 Thyroid function test5 &thers5 TREATMENT PLAN Please include procedures done/planned for the patient E7PECTATIONS FROM THE PSYCHIATRIST . / "valuation and &pinion . / Treat0ent 9 Co 0ana1e0ent . / Psycholo1ical support for5 + - patient Plan of Mana1e0ent . / Patient directed + - Psychophar0acolo1y + - Psychotherapy + - Individual, type + - $a0ily . / Consultee directed Specify5 . / Staff directed Specify5 ,isposition of patients . / &P, follo3 up . / 8ard A ad0ission . / ,ied . / HAA . / ,ischar1ed 3ithout notification

PGH Form No P-450002 rev02.09 upmed2010

+ - fa0ily + - staff . / &thers +please specify-5

. / )o intervention . / ,ischar1e fro0 service $inal date of si1n out5 ,ate dischar1ed5 Total B of days seen5 Total B of H,5