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Initial psychiatric assessment: A practical guide to the ...

BC MEDICAL JOURNALVOL. 45NO. 4, MAY2003174 Initial psychiatric assessment : a practical guide to the clinical interview1. ID2. HPI ONSET, DURATION, COURSEName: _____Marital status:_____Sex: _____Occupation: _____DOB: _____ Age: _____Financial situation: _____(Why present now/precipitants/stressors? When it started? How long it lasts/frequency? What is it like? Impact on life)For episodic illnesses describe first episode:1. Onset:2. Precipitants:3. Duration:4. Rx response:DEPRESSION ( Sigecaps )MANIA( Giddiness )PSYCHOSISPANIC ATTACKS Low mood for >2 weeksGrandioseHallucinations/illusionsTr emblingSleepIncreased activityDelusionsPalpitationsInterestgoa l-directed/high riskSelf-reference:Nausea/chills Guilt/worthlessnessDecreased judgmentpeople watching youChoking/chest painEnergyDistractibletalking about youSweating ConcentrationIrritabilitymessages from mediaFear:Appetite/weight Need less sleepThought blocking/insertiondying/going crazyPsychomotor slowingElevated moodDisorganization:Anticipatory anxietySuicide:Speedy talkingspeech/behaviorAvoidance Hopelessness/Plan/AccessSpeedy thoughtsAgoraphobiaGENERALIZED ANXIETYOBSESSIVE-COMPULSIVE DISORDERPTSDE xcess worryIntrusive/persistent thoughts Experienced/witness eventRestless/edgyRecognized as excessive/irrationalPersistent re-experiencingEasily fatiguedRepetitive behaviors.

Initial psychiatric assessment: A practical guide to the clinical interview 8. MSE 9. FOLSTEIN MMSE Appearance: Orientation: /10 Time: year Behavior: season month Speech: date day Emotion: Affect and mood Place: floor building Perception: city province Thought process: country Thought content: Immediate recall: /3 Attention: /5 Concentration ...

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