CMN548 unit 1: Psychiatric history and psychiatric
assessment UPDATED ACTUAL Questions and
CORRECT Answers
Elements of the psychiatric interview-2 patient history (subjective info) and mental status exam (objective info)
,Sadock -Complete psychiatric assessment 1) Identifying data: pt name.sex/,arital status/race/ethnicity/occupation.
2) Source and reliability: Where information is coming from (patient/chart/family)
how reliable information is- use own judgment
3) Chief Complaint: Pts own statement of why they are here>
4) HPI History of present illness: chronological description of current episode
include changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
Include Psychiatric Review of Systems:
Mood/anxiety/psychosis/other
Mood- depressive symptoms- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
Mood-Mania impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts
/excessive energy
Mood-mixed: irritability/liability
ANXIETY
Generalized anxiety sx
( where when who/how long/how frequent
Panic D/O-
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
OCD symptoms:
checking/rituals/organizing rational vs irrational beliefs
PTSD:
nightmares, startle response/flashbacks/avoidance
Social Anxiety Symptoms/Simple phobias
Psychosis
Hallucinations
- Auditory/visual olfactory/tactile
Paranoia
, Delusions
- TV,radio, thought broadcasting/referential thinking/
Patient perceptions:
spiritual beleifs/reality testing
Other: ADHD -hyperactivity Eating D/O.
5) Past Psychiatric History:
All psych illnesses/course/ past treatments hospitalizations. Medications used
how long a trial - Side effects problems with treatment. Past Suicide attempts,
violence/legal complications. Hx of self-injurious behavior.
6) Substance Abuse/Use and Addictions:
Use of alcohol/drugs/medications- Use CAGE - Cut down, Annoyed by others
asking to cut down/Guilty about drinking/Eye-opener
RAPS4- Remorse,Amnesia, Perform,Starter.
Note periods of sobriety/length of time /history of treatment.
Readiness for change. Also include Tobacco and caffeine/gambling/eating
behaviors/internet.
6) Past Medical History
Major medical illnesses, surgeries, medication taking -compliance with possible
SE that could contribute to dx. Allergies. Neuro symptoms. Primary care
physicians other medical specialists.
7) Family History
Psychiatric diagnoses, medications, hospitalizations, potential support, substance
abuse, suicides/lethality Medical illnesses such as diabetes hyperlipidemia.
8) Developmental and Social History:
developmental milestones: crawling walking, childhood home and school
environment m number and quality of friendships, education history, special
education, learning disorders, academic performance. Childhood physical and
sexual abuse,
*Work history , current job, problems with supervisors co-workers, Income./
*financial concerns. Insurance coverage and pharmacy may be noted in this
section.
Military history
Marriage and family relationships
, sexual preferences , available support, hobbies, interests, cultural and religious.
Legal.
9) Review of Systems: Organized by Major systems of body. See Section 1 Carlat
10) Mental Status Exam
1) Appearance and behavior
2) Motor activity - agitated slow, gait, freedom of movement, postures, pacing,
tics, jittery, lip smacking, tongue protrusion
assessment UPDATED ACTUAL Questions and
CORRECT Answers
Elements of the psychiatric interview-2 patient history (subjective info) and mental status exam (objective info)
,Sadock -Complete psychiatric assessment 1) Identifying data: pt name.sex/,arital status/race/ethnicity/occupation.
2) Source and reliability: Where information is coming from (patient/chart/family)
how reliable information is- use own judgment
3) Chief Complaint: Pts own statement of why they are here>
4) HPI History of present illness: chronological description of current episode
include changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
Include Psychiatric Review of Systems:
Mood/anxiety/psychosis/other
Mood- depressive symptoms- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
Mood-Mania impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts
/excessive energy
Mood-mixed: irritability/liability
ANXIETY
Generalized anxiety sx
( where when who/how long/how frequent
Panic D/O-
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
OCD symptoms:
checking/rituals/organizing rational vs irrational beliefs
PTSD:
nightmares, startle response/flashbacks/avoidance
Social Anxiety Symptoms/Simple phobias
Psychosis
Hallucinations
- Auditory/visual olfactory/tactile
Paranoia
, Delusions
- TV,radio, thought broadcasting/referential thinking/
Patient perceptions:
spiritual beleifs/reality testing
Other: ADHD -hyperactivity Eating D/O.
5) Past Psychiatric History:
All psych illnesses/course/ past treatments hospitalizations. Medications used
how long a trial - Side effects problems with treatment. Past Suicide attempts,
violence/legal complications. Hx of self-injurious behavior.
6) Substance Abuse/Use and Addictions:
Use of alcohol/drugs/medications- Use CAGE - Cut down, Annoyed by others
asking to cut down/Guilty about drinking/Eye-opener
RAPS4- Remorse,Amnesia, Perform,Starter.
Note periods of sobriety/length of time /history of treatment.
Readiness for change. Also include Tobacco and caffeine/gambling/eating
behaviors/internet.
6) Past Medical History
Major medical illnesses, surgeries, medication taking -compliance with possible
SE that could contribute to dx. Allergies. Neuro symptoms. Primary care
physicians other medical specialists.
7) Family History
Psychiatric diagnoses, medications, hospitalizations, potential support, substance
abuse, suicides/lethality Medical illnesses such as diabetes hyperlipidemia.
8) Developmental and Social History:
developmental milestones: crawling walking, childhood home and school
environment m number and quality of friendships, education history, special
education, learning disorders, academic performance. Childhood physical and
sexual abuse,
*Work history , current job, problems with supervisors co-workers, Income./
*financial concerns. Insurance coverage and pharmacy may be noted in this
section.
Military history
Marriage and family relationships
, sexual preferences , available support, hobbies, interests, cultural and religious.
Legal.
9) Review of Systems: Organized by Major systems of body. See Section 1 Carlat
10) Mental Status Exam
1) Appearance and behavior
2) Motor activity - agitated slow, gait, freedom of movement, postures, pacing,
tics, jittery, lip smacking, tongue protrusion
