CMN 548 Module 1 Verified Exam Guide 2025

CMN 548 Module 1 Verified Exam Guide 2025 Identifying data Topic Name, age, sex, marital status, religion, education, address, phone number, occupation, source of referral Identifying data Questions Be direct in obtaining identifying data. Request specific answers. Identifying data Comments and helpful hints If patient cannot cooperate, get information from family member or friend; if referred by a physician, obtain medical record. Chief complaint (CC) topic Brief statement in patient's own words of why patient is in the hospital or is being seen in consultation Chief complaint (CC) questions Why are you going to see a psychiatrist? What brought you to the hospital? What seems to be the problem? Chief complaint (CC) comments and helpful hints Record answers verbatim; a bizarré complaint points to psychotic process. History of present illness (HPI): Development of symptoms from time of onset to present; relation of life events, conflicts, stressors: drugs; change from previous level of functioning History of present illness (HPI): questions When did you first notice something happening to you? Were you upset about anything when symptoms began? Did they begin suddenly or gradually? History of present illness (HPI): comments and helpful hints CMN 548 CMN 548 Record in patient's own words as much as possible. Get history of previous hospitalizations and treatment. Sudden onset of symptoms may indicate drug-induced disorder. Previous psychiatric and medical disorders: Psychiatric disorders; psychosomatic; medical, neurologic illnesses (e.g., craniocerebral trauma, convulsions). Previous psychiatric and medical disorders: QUESTIONS Did you ever lose consciousness? Have a seizure? Previous psychiatric and medical disorders: comments and helpful hints Ascertain extent of illness, treatment, medications, outcomes, hospitals, doctors. Determine whether illness serves some additional purpose (secondary gain). substance use/abuse Substance use disorders can mimic or induce psychiatric syndromes, elevate risk of suicide and violence, and have important impact on safe medication prescribing. Various tools can be used to aid in gathering the substance use history. Examples include the commonly used CAGE questionnaire which has been modified to include other drugs (and now called CAGE-AID) Past medical history The interviewer is interested in obtaining an accounting of major medical disorders both to develop a complete history and to identify illness that could mimic a psychiatric disorder, contribute to the context of the presentation or factor into treatment planning. Family History (FH): topic Psychiatric, medical, and genetic illness in mother, father, siblings; age of parents and occupations; if deceased, date and cause; feelings about each family member, finances . Because many psychiatric illnesses have a genetic predisposition, if not cause, a careful review of family history is important to the assessment and can aid in diagnosis and establishing expected prognosis . Family History (FH): question CMN 548 CMN 548 Have any members in your family been depressed? Alcoholic? In a mental hospital? In jail? Describe your living conditions. Did you have your own room? Family History (FH): comments and helpful hints Genetic loading in anxiety, depression, schizophrenia. Get medication history of family (medications effective in family members for similar disorders may be effective in patient). developmental and social history The developmental and social history reviews the stages of the patient's life from gestation to the present with an eye toward understanding the important exposures, relationships, and events that shaped the person's life story. It is often helpful to review the social history chronologically; doing so provides a natural flow to the questions and ensures a complete history. Review of systems As in a general medical interview, the review of systems is intended to capture any current physical signs and symptoms not already identified in the HPI or past medical history (including Table 7.1-2 and is organized by asking sentinel questions about the major systems of the body). review of systems: sleep Sleep phase problems (initial, middle, terminal insomnia), total sleep time, abnormal sleep events review of systems: mood depression Depression: persistent sadness, reduced interest or pleasure in usual activities, tearfulness, reduced or excessive sleep, reduced or increased appetite, weight loss or gain, low energy, reduced concentration, low libido, excessive or inappropriate guilt, psychomotor change (slowing or agitation), negative self-appraisal, helpless and hopeless thinking thoughts of death or suicide. A common mnemonic used to remember the symptoms of major depression is SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidality). review of systems: mood Hypomania/mania CMN 548 CMN 548 Hypomania/Mania: elevated, expansive or irritable mood, decreased need for or inability to sleep, excessive energy, marked increase in goal and pleasure directed activity, increase amount and pace of speech and thought, grandiosity, heightened libido, impulsivity and/or recklessness in behaviors such as spending and sex review of systems: anxiety Anxiety Experience of panic attacks, somatic symptoms of anxiety, phobic, or social avoidance review of systems: psychosis Experience of hallucinations, delusions, disorganized behavior, speech or thought, negative symptoms review of systems: obsessive-compulsive Repetitive intrusive and unwanted thoughts, compulsive behaviors to neutralize anxiety, hoarding behaviors review of systems: trauma Traumatic exposure; intrusive and avoidance symptoms, negative alterations in cognitions and mood, excessive arousal and reactivity review of systems: behavior Substance use, gambling, impulse control problems, disordered eating, repetitive self harm mental status exam The MSE is the functional equivalent of the physical examination in other areas of medicine. It is a systematic collection of the observations (e.g., signs such as blunt affect or rapid speech) and reported mental experiences (e.g., symptoms such as depressed mood or hallucinations) that produce a picture of the patient's current mental state. The interviewer makes these observations throughout an encounter and ultimately documents the findings together in the MSE section of the evaluation document. physical exam Psychiatrists do not usually personally conduct comprehensive physical examinations but may conduct focused examinations such as neurological or thyroid examinations. In CMN 548 CMN 548 the outpatient setting, the psychiatrist generally relies on the PCP to conduct the physical examination and it is useful in the initial evaluation to record the date of the most recent physical examination and review of recent laboratories if results are available. plan formulation The formulation should include a brief summary of the relevant findings from the history and examination including the psychosocial contexts in which the problem has developed and comments on the relevant contributions to the prese