CMN548 unit 1: Psychiatric history and
psychiatric assessment exam
Elements of the psychiatric interview-2 - Correct Answers -patient history (subjective
info) and mental status exam (objective info)
Sadock -Complete psychiatric assessment - Correct Answers -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 attempt
Identifying data - Correct Answers -patient's name, age, sex, marital status/ significant
other, race, ethnicity, occupation
source and reliability - Correct Answers -clarify where the information came from and
how reliable the data are
chief complaint - Correct Answers -Patient's presenting condition in their own words
MSE evaluation of perceptual disturbances - Correct Answers -Hallucinations/type/
content/depersonalization.
MSE evaluation of cognition - Correct Answers -alertness, orientation, concentration,
memory/recent remote, immediate.
, MSE evaluation of abstract reasoning - Correct Answers -ability to shift back and forth
from general concepts and specific examples. Like objects- fruit apple and pear,
bus/airplane. Proverbs- cry over spilled milk.
MSE evaluation of insight - Correct Answers -why they are hear,do they think need
help. Partial, full none.
MSE evaluation of judgement - Correct Answers -capacity to make good decisions.
Participation in dangerous activities,
what does the mental status exam also include - Correct Answers -a cognitive screen,
most often the mini-mental status exam
The history of present illness definition - Correct Answers -the chronological description
of the evolution of the symptoms of the current episode
History of present illness: What to include - Correct Answers -*Chronological description
of the evolution of the symptoms of the current episode.
*Any changes that have occurred:* interests, relationships, behaviors, personal habits,
physical health.
*Ask open ended questions to get the info ("Can you tell me what brings you here
today?")
*Length of time that the current sx have been present
*Fluctuations of sx in severity or nature of sx over time?
*Presence of absence of stressors
*Factors that alleviate or exacerbate sx
*Has the person already sought treatment? (if so, who patient saw, what was done, how
often, modality, continuing treatment?)
Essential question to ask for the history of present illness interview - Correct Answers -
*What symptoms
*Severity of sx
*How long sx present
*Associated factors
*Why the patient is seeking help now?
*Triggering factors
*Setting in which the illness began (to understand etiology and significant contributions)
psychiatric assessment exam
Elements of the psychiatric interview-2 - Correct Answers -patient history (subjective
info) and mental status exam (objective info)
Sadock -Complete psychiatric assessment - Correct Answers -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 attempt
Identifying data - Correct Answers -patient's name, age, sex, marital status/ significant
other, race, ethnicity, occupation
source and reliability - Correct Answers -clarify where the information came from and
how reliable the data are
chief complaint - Correct Answers -Patient's presenting condition in their own words
MSE evaluation of perceptual disturbances - Correct Answers -Hallucinations/type/
content/depersonalization.
MSE evaluation of cognition - Correct Answers -alertness, orientation, concentration,
memory/recent remote, immediate.
, MSE evaluation of abstract reasoning - Correct Answers -ability to shift back and forth
from general concepts and specific examples. Like objects- fruit apple and pear,
bus/airplane. Proverbs- cry over spilled milk.
MSE evaluation of insight - Correct Answers -why they are hear,do they think need
help. Partial, full none.
MSE evaluation of judgement - Correct Answers -capacity to make good decisions.
Participation in dangerous activities,
what does the mental status exam also include - Correct Answers -a cognitive screen,
most often the mini-mental status exam
The history of present illness definition - Correct Answers -the chronological description
of the evolution of the symptoms of the current episode
History of present illness: What to include - Correct Answers -*Chronological description
of the evolution of the symptoms of the current episode.
*Any changes that have occurred:* interests, relationships, behaviors, personal habits,
physical health.
*Ask open ended questions to get the info ("Can you tell me what brings you here
today?")
*Length of time that the current sx have been present
*Fluctuations of sx in severity or nature of sx over time?
*Presence of absence of stressors
*Factors that alleviate or exacerbate sx
*Has the person already sought treatment? (if so, who patient saw, what was done, how
often, modality, continuing treatment?)
Essential question to ask for the history of present illness interview - Correct Answers -
*What symptoms
*Severity of sx
*How long sx present
*Associated factors
*Why the patient is seeking help now?
*Triggering factors
*Setting in which the illness began (to understand etiology and significant contributions)
