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1. GUIDE SADOCK Complete the following table which outlines the elements of the initial
psychiatric Chapter 7.1 - 7.2, interview: 7.6
2. Identifying data Topic Name, age, sex, marital status, religion, education, address, phone
number, occupation, source of referral
3. Identifying data Be direct in obtaining identifying data. Request specific answers.
Questions
4. Identifying data If patient cannot cooperate, get information from family member or
Comments and friend; if referred by a physician, obtain medical record.
helpful hints
5. Chief complaint (CC) Brief statement in patient's own words of why patient is in the hospital
topic or is being seen in consultation
6. Chief complaint (CC) Why are you going to see a psychiatrist? What brought you to the
questions hospital? What seems to be the problem?
Record answers verbatim; a bizarré complaint points to psychotic
7. Chief complaint process.
(CC) comments and helpful hints
,8. History of pre- Development of symptoms from time of onset to present; relation of
life events, sent illness (HPI): conflicts, stressors: drugs; change from previous level of
functioning
9. History of pre- When did you first notice something happening to you? Were you
upset about sent illness (HPI): anything when symptoms began? Did they begin suddenly or
gradually? questions
10. History of pre- Record in patient's own words as much as possible. Get history of
previous hospisent illness (HPI): talizations and treatment. Sudden onset of symptoms may
indicate drug-induced disorder.
comments and helpful hints
11. Previous psychi- Psychiatric disorders; psychosomatic; medical, neurologic illnesses
(e.g., cranioatric and medical cerebral trauma, convulsions). disorders:
12. Previous psychi- Did you ever lose consciousness? Have a seizure?
, atric and medical
disorders: QUESTIONS
13. Previous psychi- Ascertain extent of illness, treatment, medications, outcomes,
hospitals, doctors.
atric and medical Determine whether illness serves some additional purpose (secondary gain).
disorders: comments and helpful hints
14. substance Substance use disorders can mimic or induce psychiatric syndromes,
elevate use/abuse risk of suicide and violence, and have important impact on safe medication
prescribing.
Various tools can be used to aid in gathering the substance use history. Examples include the
commonly used CAGE questionnaire which has been modified to include other drugs (and now
called CAGE-AID)
15. Past medical his- The interviewer is interested in obtaining an accounting of major
medical disortory ders both to develop a complete history and to identify illness that could
mimic
a psychiatric disorder, contribute to the context of the presentation or factor into treatment planning.
, 16. Family History Psychiatric, medical, and genetic illness in mother, father, siblings; age
of parents (FH): topic and occupations; if deceased, date and cause; feelings about each family
member, finances .
Because many psychiatric illnesses have a genetic predisposition, if not cause, a careful review of
family history is important to the assessment and can aid in diagnosis and establishing expected
prognosis .
17. Family History Have any members in your family been depressed? Alcoholic? In a
mental hospital? (FH): question In jail? Describe your living conditions. Did you have your
own room?
18. Family History Genetic loading in anxiety, depression, schizophrenia. Get medication
history of (FH): comments family (medications effective in family members for similar
disorders may be and helpful hints effective in patient).
19. developmental The developmental and social history reviews the stages of the
patient's life and social history from gestation to the present with an eye toward understanding
the important
20. Review of 21. review of systems: sleep
systems
22. review of systems: mood depression