Identifying Information

Source and Reliability

Chief complaint/concern

History of Present illness (HPI)

Past Medical History

Past Psychiatric History

Personal and Social History

Family History

General Symptoms – Review of Systems

  Psychiatric – Mental health Status/Behavioral Assessment

Physical Examination - MMSE, Fund of General Information, Abstraction Ability

Identifying Information:

Who is giving the information and how reliable do you believe they are reporting  their symptoms or situation. Were there any interfering factors during the interview.  What is the outward expression of the individual receiving treatment toward the physician and the other members of the treatment team.  Describe the type and degree of cooperativeness both currently and recently.

One or more reasons to seek care, often include duration of symptom usually brief statement in patients own words if possible with quotation marks if patients words are used.

The details of the chief complaint including the seven descriptors of symptoms.  Include patient’s thoughts and feelings, remember to document about their thoughts on attribution, their concerns and impact on their life.  Also include pertinent positives and negatives related to the complaint and the differential diagnosis or warning signs.  You may include other information when appropriate like medications, allergies, habits like smoking or risk factors for disease if pertinent to the problem or differential diagnosis.

If relevant, a summary is needed regarding the individual’s most recent symptoms, when they started, the course these symptoms have taken, exacerbating and /or alleviating factors, previously tried and currently used treatments (medications, over-the-counter remedies, natural, herbal, religious, and cultural approaches) and what circumstances have lead to admission.  Also record any recent life changes or stressors, any severe conflicts or challenges, and any possible secondary gain that might be influencing  the person’s symptoms. 

Current Medications and Allergies

List all current medications the patient is taking along with any Allergies

Past Medical History

General State of Health:

Medical Illnesses, Hospitalization, Venereal Diseases: Include current and past significant medicals problems in childhood and adulthood if relevant and their treatments

Surgeries:

Trauma:

Immunizations:

Sleep Patterns:

A record of the patient’s mental health throughout their life:

To understand who the patients is

Where the patient has come from

Where the patient is likely to go in the future

Told in the patient’s own words from his/her point of view (open-ended questions are key!!)

A thorough Psychiatric History is essential for correct diagnosis and case formulation

(Always sit close to the door). 

-Delusion: belief in something false (we are not on St. Maarten).

-Don't take notes in front of paranoid patients.

1. Professional Dress

2. Keep an even playing field with the patient

3. Evaluate aggressiveness

4. Protect self and the patient

5. Address hopeless feelings

6. Challenge delusional thinking?

7. Be specific about suicidal thoughts

8. Allow long pauses

9. Note taking is OK “sometimes”

Past Psychiatric History

 Developmental History

  1. Prenatal and perinatal

  2. Early childhood (through age 3)

  3. Middle childhood (ages 3–11)

  4. Late childhood (puberty through adolescence)

  The physician should describe the presentation and history of previous mental symptoms including a summary of previous outpatient and inpatient treatment, their effectiveness, and the individual’s compliance with these treatments.

  An estimate of the age of the individual at the time of initial onset of symptoms,  the dates of the first and the last hospitalizations, and an approximation of the number of hospitalizations, of obtainable should be included.

  A discussion of previous medications, therapies, and ECT should be included.  A history of previous suicide attempts, crimes, alcohol abuse, substance abuse and toxin exposure, if applicable, should be obtained.  Record specifics regarding previous suicide attempts, crimes, alcohol or substance abuse.  Include collateral information from others.

  List any risk factors found.

Personal and Social History

Education:  What educational level has been achieved?- (ex. – certifications, diplomas, highest grade level, GED).  Document learning difficulties, literacy problems, special education and language barriers that might impact care.

Occupational/Work history including military service:  The physician should obtain information about types of employment, how long held, and why discontinued.  If relevant to the interview, what the “best” job obtained and when?  What were the relationships with co-workers and bosses like?  How did the jobs compare with the person’s ambitions and with the expectations of the family or significant others?

Home Situation:

Relationships:  Family relationships should be explored for stability including any history of abuse or violence.  Information regarding number of marriages, at what age, to whom and reasons for separations and/or divorces should be obtained.  If relevant to the interview, relationship patterns in marriage, number of children and the individual’s interactions and attitudes toward them are also important to document.

Sexual history: The person’s sexual orientation and partners should be explored, and if significant or relevant, feels and attitudes about sexual activity, first sexual experience, sexual problems and deviations should be documented.

1. State context Stating the context or rationale for the sexual inquiries will facilitate the interview. The physician may acknowledge that such discussions are difficult and can be embarrassing, but are nevertheless important

2. Transition Try to put patients at ease and let them know that taking a sexual history is an important part of a regular medical exam or physical history.

3. Start Open-Ended

4. Vague answers should prompt more detailed questioning.  You indicated that you were “not especially happy” about your sexual activities, please tell me more about this.

The 6 P’s

These are the areas that you should openly discuss with your patients.

You will ask additional questions that are appropriate given a specific patient. Not all areas need to be explored with every patient.

The six “P”s stand for:

Partners

Practices

Protection from STDs

Past history of STDs

Prevention of pregnancy

Performance changes

Current household:

Leisure activities:

Religious or Spiritual Beliefs:

Diet:

Exercise:

Substance Abuse History:  Use the CAGE, state substances currently used including herbal remedies and supplements.  If relevant,  think about the onset of substance abuse and its relationship to the onset of psychiatric symptoms: which came first?  Document at what age did this person start to use various substances and at what age was this individual possibly exposed to other toxins.  With regard to these substances, give specific names, amounts of exposure, signs of intoxication, withdrawal, or toxicity, the relationship to mental illness, and the last use or exposure.  Record any treatments received.

  ETOH

  Smoking and other tobacco products

  Caffeine

  Illicit Drugs

  Unprescribed medications

Safety Measures:  Assess whether the patient uses safety measures such as seatbelt, sunscreen and smoke detectors.  Assess risks in environment if relevant.

Family History

Outlines or family pedigree with age and health or age and cause of death of siblings, parents, grandparents.  Document specific illnesses in the family such as CAD, hypertension, cancer, diabetes, dementia, etc.

Additionally, what family history is important to the overall treatment and care of this individual?  If relevant,  this may include a description of the family members and the relationship with them.  History of psychiatric illnesses, as well as alcohol abuse, substance abuse, suicide, and criminal activity is important.  A history of the origin of the family and the person’s role in it may also  be helpful.

General symptoms:

Review of Systems:  Most not relevant to these interviews

Psychiatric – Mental Health Status/Behavioral Assessment:

more focused and includes questions and assessment of specific domains.  Specific tasks are also completed during this type of examination.

Assumptions:

  History is stable

  Mental Status can change

-To obtain a cross sectional description of an individuals current mental state (evaluate emotional, behavioral or cognitive problems)

-This information is to be combined with the biographical and historical  information

-Aids in formulation and diagnosis which drives treatment planning

-It establishes a baseline against which to measure change over time

No****

While the MSE is almost always used when evaluating psychiatric patients it can be a helpful way to approach other individuals with more subtle psychological distress

i.e. distress secondary to a medical condition or subclinical psychological problems

Mental Status Examination

-The bottom line

The Mental Status Examination is useful for assisting in understanding, diagnosing, and measuring the progress or deterioration of your patients cognitive states

It facilitates communication among professionals

In order to successfully complete the MSE the clinician must:

Listen empathetically

Build rapport with the patient

Help the patient to feel secure and understood

Maintain the confidentiality of the relationship

Reduce variables that interfere with the accuracy of the information obtained

Relationship of the Mental Status Examination to the Mini Mental State (Status)  Examination

MSE Outcome

Decisions that may be considered based on the results of a MSE include:

Motor Activity

-How is there level of action?

•(Psychomotor) activity

Here we want to describe the manner of speech not the content

Rate of speech (rapid, slowed, slurred, stuttering)

Volume of speech (psychosis, depression, deafness)

Poverty of speech - amount of speech

Poverty of content – vague but of adequate amount

Pressured speech – rapid and difficult to interrupt

Volubility (logorrhea)– copious, coherent, logical speech

Nonspontaneous speech – no self initiation of speech (only answers direct questions)

Dysprosody – loss of normal speech melody

Dysarthria – articulation difficulty (difficulty saying certain letters).

Cluttering – erratic and dysrhythmic speech, consisting of rapid and jerky spurts

Volubility = fluency

Logorrhea – pathological and excessive often incoherent speech

1. Important to consider medical causes for speech disturbances

2. Speech characteristics can be a clue to drug intoxication

3. Speech is a “window” to thought processes

Speech:  Describe the patient’s speech with regard to rate, rhythm, volume, and quality.  Are there speech impediments, pronunciation problems, or content suggesting an aphasia, a phonological problem, or stuttering.  Is the speech sparse or does it contain neologisms, echolalia (repeats a person’s speech), or other indications of possible illness.

Observed emotional responses during the clinical interview (the tone of the interview).

Unpleasant Mood 

Clang associations – connected illogically by rhyming or puns

Echolalia – person repeats what you say (copy cat)

Neologisms – invented or condensed words that have meaning only to the the patient (quantrum).

Perseverations – involuntarily responding to all questions in the same way.

Word salad – nonsense words and phrases.

Looseness of associations – jumps from one topic to another, the connection between the topics is lost

Blocking – sudden lapse of thought mid sentence without recovery of train of thought

Circumstanitiality – absence of direction toward a goal of thought.  Very detail oriented, they get stuck but do come to a conclusion

Tangentiality – severe circumstantiality  where the individual strays completely from the topic and includes thoughts seem to be totally unrelated or irrelevant (Seen in Schizophrenia most commonly)

-most common in lesions of the right parietal lobe

-right thalamic or basal ganglia lesions