Interview
Allow the patient to speak freely and encourage with open-ended questions
CC: Quote the patient.
HPI:
Identifying Information: Age, sex/gender, relationship status, employment, living condition, past psychiatric history, who presents with [symptoms] in context of [stressor].
OPQRST
Onset: sudden or insidious Precipitants: events, drugs or alcohol, etc. (context of symptoms) Quality: character of the symptom(s) Radiation: any associated symptoms Severity: the impact on patient’s life, daily functioning, family and friends Timing: intermittent vs. constant; what makes it better? Worse?
Psychiatric Review of Symptoms (see below)
Past Psychiatric History
First psychiatric contact: what led to it? Past hospitalizations: how many? For what? Any state hospitalizations? Past suicide attempts or self-harm (cutting, burning, purging): When, what, context, results Past aggression/violence toward others: When, what, context, results Medication history (when, how long taken, benefits or adverse side effects) Current psychiatric care
Substance Abuse History
Name them for the patient (EtOH, marijuana, heroin, cocaine) Amount and Duration of use Precipitants, Attitude toward use; How does it affect life? History of withdrawal symptoms Past treatments, including rehab; longest time sober?
Family History
Biological relatives with psychiatric illness: Mood, psychosis, substance use, dementia Family history of suicide (attempts and completed) Relevant family medical history
Social History
Born and raised: What was your childhood like? Who was in the house? Sexual and relationship history Education (how far? where?) Employment Religious affiliation, Cultural background Legal (h/o violence or arrests) Current living situation, sources of support (emotional and financial) Abuse or Trauma: Physical, Sexual, Emotional, Neglect? If yes, once or ongoing? Lasting sequelae?
Past Medical History
Mental Status Exam
Psychiatric Review of Symptoms
Depressive:
S: Have you had periods of feeling sad, despondent or hopeless? I: Have you noticed a change in your interest in things you normally enjoy? G: Have you been feeling down on yourself? Guilty about anything? E: Have you tended to feel more tired than usual? As if all your energy is drained? C: Have you had trouble concentrating? Making decisions? A: Have you had any changes in your appetite? Lost or gained weight? P: Have you felt restless or agitated? Have you been feeling slowed down? S: have you had a change in your sleep pattern? Eg, trouble sleeping? (initial, middle, terminal) S: Have you ever felt that life isn’t worth living? Thought about taking your own life?
Anxiety/OCD:
Are you someone that people tend to think of as a worrier? Do you ever feel like your anxiety is out of control? Have you ever experienced a sudden attack of panic or fear in which you felt extremely uncomfortable? Did you feel as if you were going to die or go crazy?
Mania:
DIGFAST (distractibility, insomnia, grandiosity, flight of ideas, activity, speech, thoughtlessness) Have you ever felt extremely good or high, different from your normal self, for several days in a row? Have you ever had several days in a row when your thoughts are racing so fast you have trouble keeping up, and people tell you that you are talking more quickly than usual? Have you ever had several days in a row when you felt like you didn't need to sleep, and yet still had lots of energy? Have you ever had several days in a row when you did really risky, impulsive things, such as spending lots of money, and didn't care about the consequences as you normally would?
Psychosis
Delusions: Persecutory: Have you felt that people are against you? Trying to harm you in any way?, Grandiose: Have you ever though you might have special powers, talents or abilities?, Thought broadcasting: Have you heard your own thoughts out loud, as if they were a voice outside your head, or felt like other people could hear your thoughts? Or that other people might be stealing your thoughts, or putting thoughts into your head? Hallucinations: Have you heard voices no one else could hear? Or when no one was around and you couldn’t account for them? Or seen things that didn't seem to really be there?
Mental Status Exam
Appearance: Attire, grooming, distinguishing features Attitude/Behavior: Cooperation, demeanor, eye contact, posture, psychomotor agitation/retardation Speech: Spontaneity, fluency, rate, rhythm, volume Mood: How patient reports he/she is feeling; quote Affect: Quality, intensity, changeability, reactivity, appropriateness Thought Process: Linear, Circumstantial, Tangential, Flight of ideas, Loosening of associations, Derailment, Slowed, Thought blocking, Perseverative (vs. ruminative, preoccupied with, focused on, etc.) Thought Content: Delusions, preoccupations Suicidal/Homicidal Ideation: Passive/active, plan, intent, timeline Perception: Auditory and visual hallucinations Insight/Judgment: Recognition of symptoms, risky behaviors, adherence with care Cognitive Exam: Orientation to person, place, and time; attention/concentration (months of year backward), 3-item recall, language (naming objects, repeating phrases, performing commands), calculations, visuospatial (copy figure)
Major causes of delirium
I WATCH DEATHI nfectionW ithdrawal (from benzos)A cute metabolicT raumaC NS pathologyH ypoxiaD eficiencies (vitamins)E ndocrineA cute vascular accident/MIT oxins/drugsH eavy metals
Symptoms of depression
SIG-E-CAPS
S leep (hypersomnia or insomnia)
I nterest (loss of interest in activities pt once enjoyed)
G uilt (inappropriate guilt, feelings of worthlessness)
E nergy (decreased)
C oncentration (decreased)
A ppetite (increased or decreased)
P sychomotor agitation/retardation
S uicidal ideation
P LUS Depressed mood or irritability