Psychiatric history and
psychiatric assessment
Questions and Complete
Solutions Graded A+
Elements of the psychiatric interview-2 - Answer: patient history (subjective info) and mental status
exam (objective info)
Sadock -Complete psychiatric assessment - Answer: 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 - Answer: patient's name, age, sex, marital status/ significant other, race, ethnicity,
occupation
source and reliability - Answer: clarify where the information came from and how reliable the data are
chief complaint - Answer: Patient's presenting condition in their own words
The history of present illness definition - Answer: the chronological description of the evolution of the
symptoms of the current episode