HISTORY:
for
Severity: , significant distress
Negative impact on:
Reaction to stressors is than would normally be expected
Treatments tried: ,
Other elements:
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
DDx:
PLAN:
- Blood work: ,
- Psychoeducation about borderline personality disorder
- Dialectical behavior therapy
- Cognitive behavioral therapy
- Mindfulness-based cognitive therapy
- Schema-focused therapy
- Advised that medication is not always helpful
-
-
-
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts