Initial Information
- Demographics
- Chief complaint
- Hx of present illness
- Psychiatric functional inquiry
- Anxiety: Worries, obsessions, compulsions, panic attacks, phobias
- Psychosis: hallucinations, delusions, thought form disorders
- Suicide/homicide: ideation, plan, hx of attempts
- Organic: ethanol, drug use, illness, dementia
Mental Status Exam
- Appearance
- Friendly
- Cooperative
- Withdrawn
- Uncommunicative
- Hostile
- Guarded
- Does the patient appear his stated age?
- Describe facial expression as well as condition and dress.
- Evidence for tattoos, piercing, scar, …
- Is patient responsive? alert? cooperative? calm? Agitated?
- Mood:
- Depressed
- Manic
- Anxious
- Angry
- Elated
- Fearful
- Affect:
- Normal
- Flat
- Restricted
- Appropriate/Inappropriate for mood
- Stable vs. Labile (in response to changes in conversation)
- Speech
- Rate? Is it monotone?
- What is the rhythm? Is there an increase in latency?
- What is the level of the vocabulary? Is there neologism (words invented by connecting syllables in a fashion to produce a new word)?
- Perception:
- Hallucination:
- Getting messages from television
- Illusion
- Depersonalization
- Derealization
- Hallucination:
- Thought:
- Thought Form:
- Flight of Ideas describes speech in which one idea is quickly followed by another.
- Logic: Loosening of Associations is the generic description of thought in which the logicality and sequentiality of the ideas breaks down
- Circumstantiality:
- involves inclusion of too many trivial details. It is logical and sequential thus the connection between ideas is easily understood.
- Tangentiality:
- also appears to be sequential but the patient goes off on a tangent and does not arrive at the goal.
- Perseveration
- Thought blocking
- Clang association
- Thought Content: GST PAID
- Grandiosity: self-esteem/confidence, special talents, going to be famous
- Sleep: decreased need
- Talkative: more and faster than usual, others’ noticed, get interrupted more
- Pleasurable activities: combine w/ e) for impulsivity/risky screen, sexual activities, cause problems for self/family (money, promiscuity, offending)
- Activity increased: work, chores, exercise, sex
- Ideas: flight of ideas (more ideas than N, can combine w/e)
- Distractibility: easily off track, so many things seem interesting etc…
- Thought Form:
- Insight:
- Insight:
- Impaired
- No insight, partial: eg. recognizes problem but not attributing to illness
- Full: Egodystonic vs. egosyntonic re: behavior causing problem
- Judgment :
- Poor/impaired/limited/good
- Compliance with Tx, interview etc
- Insight:
- Cognition:
- Consciousness
- Orientation: person (their name), place (city/province/country and hospital/floor/office), time (day, date, month, year, season, time)
- Memory
- Intellectual functions
Psychiatric Symptom Screen
Depression:
- Sleep
- Loss of interest
- Guilt
- Decreased Energy
- Inability to concentrate
- Loss of Appetite
- Psychomotor retardation (felling slowed down)
- Suicidal ideation
Mania:
- Impulsivity
- Pressured speech
- Increased Activity (new project, problem with sitting still)
- Insomnia
- Racing thoughts
- Esteem inflation
- Distractible
Psychosis:
- Hallucination
- Delusions
- Negative symptoms (flat affect, alogia,…)
- Disorganized speech
Anxiety:
- Panic attacks
- Recent traumatic event
- Obsessions and compulsions
Suicidal thoughts
- Ideation
- Plan
- Tools
- Attempts
Homicidal thoughts
- Plan
- Tools
Past Medical History
- Hospitalization
- Surgery
- Allergies
- HEENT
- Endocrine disorders
- Cardiovascular
- pulmonary
- Gastrointestinal
- Urological
- Musculoskeletal
- Skin
Past personal history
- Prenatal, perinatal
- Early childhood to age 3
- Middle childhood to age 11
- Late childhood to adolescence
- Adaptation or foster home experience
Substance use
- Alcohol
- Tobacco
- Opioids
- Cocaine/crack
- Amphetamines/Meth Amphetamines
- Cannabis