Transcription of Initial psychiatric assessment: A practical guide to the …
1 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.
2 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:Dreams/flashbacksMuscle tensionWashing/cleaningAvoidance behaviorsleepCounting/checkingHyper-arou sal:concentrationOrganizing/prayingvigil ance/ startleSOCIAL PHOBIABORDERLINE PESONALITYANTISOCIAL PERSONALITYP erformance situations:Fear abandonment/rejectionForensic history:Fear of embarrassmentUnstable relationshipsarrests/imprisonmentFear of humiliationChronic emptinessAggressiveness/violenceCriticis mself esteemLack of empathy/remorseIntense anger/outburstsLack of concern for safety:SPECIFIC PHOBIASSelf-damaging behaviorself or othersHeights/crowds/animalsLabile mood and impulsivityChildhood conduct disorderBODY DYSMORPHIC DISORDEREATING DISORDERSE xcess concern with appearance Binging/purging/restriction/amenorrheaor certain part of bodyPerception of body image or weightAvoidance behaviorFigure.
3 psychiatric assessment 45NO. 4, MAY2003BC MEDICAL JOURNAL175 Initial psychiatric assessment : a practical guide to the clinical interview3. psychiatric HXPrevious psychiatric Hx/Counseling/Suicide attempts/Violence:Previous diagnoses:Medications/Tx:4. FAM psychiatric HX5. MEDICAL HX6. SYSTEMS REVIEWP sychiatric Dx/Visits/Counseling/Suicide attempts:Substance use:Suicide:Previous illnesses & treatment:Surgeries/hospitalizations:Hea d injury (+/- LOC) and workup/imaging:Medications:Alcohol use:Substance use: (caffeine, nicotine, over-counter/illicit med/drugs)CNS:H & N:CVS:RESP:GI:GU:MSK:DERM:Figure (continued). psychiatric assessment MEDICAL JOURNALVOL. 45NO. 4, MAY2003176 Initial psychiatric assessment : a practical guide to the clinical interview8.
4 MSE9. FOLSTEIN MMSEA ppearance:Orientation: /10 Time:yearBehavior:seasonmonthSpeech:date dayEmotion: Affect and moodPlace:floorbuildingPerception:citypr ovinceThought process:countryThought content:Immediate recall:/3 Attention:/5 Concentration:Delay recall:/3 Naming:/2 Memory:Repetition:/13-stage command:/3 Insight:Reading:/1 Copying:/1 Judgment:Writing:/1 Suicide:Total:/307. PERSONAL HXPlace of birth:As a child: (family structure, parents occupations, relationship with parents, siblings, friends, abuse)As a teen: (friends, relationships, school, activities, sex, trouble, relationship with parents)As an adult: (work, finances, education, relationships, family, goals for future, trends in functioning)Figure (continued).
5 psychiatric assessment 45NO. 4, MAY2003BC MEDICAL JOURNAL177 Initial psychiatric assessment : a practical guide to the clinical interview10. IMPRESSION/FORMULATION BIOPSYCHOSOCIAL11. MULTIAXIAL DIAGNOSISAxis I: psychiatric disorder:Axis II: Personality:Axis III: Medical conditions:Axis IV: Social factors:Investigations:Treatment:Biologi cal:Psychological:12. PLANF igure (continued). psychiatric assessment form.
