Therapeutic ConversationClinical Journal Grading Form/Template
Brigitte Baucom Submit Date: April 5, 2012
Clinical Journal # 1 Facility: Rusk SH
I. Psychiatric Diagnosis & Definition, DSM-IV-TR Axis 1-5 & Medications – 15 pts.
Bipolar II disorder: Hypomanic episode(s) alternating with major depression. Psychosis is not present in bipolar II. The hypomania of bipolar II tends to be euphoric and the depression tends to put people at particular risk for suicide
Axis I – Bipolar II Disorder (definition above)
Axis II – Personality Disorder, Somatoform disorder - Many physical complaints affecting many organs, some dependent personality disorder traits
Axis III – General Medical Conditions – ICD-9
1. Lumbago: Pain in the muscles and joints of the lower back
2. Obesity: BMI above 30
3. Other Chronic Pain: pt. complains of back pain and other somatic pain
4. Throught 9 there was no indication in the file which leads me to believe that 4-9 are related to number 3 above
Axis IV – Psychosocial and environmental problems, pt. is unable to function in environment, i.e. occupational problems, educational problems, economic problems and interpersonal difficulties with family members and a variety of problems in other life areas.
Axis V – GAF Scale Score of 30: Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas.
* Special precautions: Visual at all times
II. Clinical Assignment – 10 pts.
Rusk State Hospital – Angelina Unit floor 2
Very interesting floor, all women. Variety of diagnosis’, all of which we have learned in class, morning was quiet, had a few new admits which were very quiet, midmorning found some pts. Very verbal and combative, by afternoon, many showed anger towards roommates while others seemed very quiet due to the medicine side effects. The pts. That had some anger where pts. That refused morning...