BRAINSCAPE1
CMN548 unit 1 Psychiatric history and
psychiatric assessment latest version
Elements of the psychiatric interview-2 - CORRECT ANSWER-patient history
(subjective info) and mental status exam (objective info)
Sadock -Complete psychiatric assessment - CORRECT ANSWER-1) *Identifying data*:
pt name.sex/,arital status/race/ethnicity/occupation.
*2) Source and reliability:* Where information is coming from (patient/chart/family) how
reliable information is- use own judgment
*3) Chief Complaint*: Pts own statement of why they are here>
*4)HPI History of present illness:* chronological description of current episode include
changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
*Include Psychiatric Review of Systems: *
Mood/anxiety/psychosis/other
*Mood- depressive symptoms*- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
BRAINSCAPE1
, BRAINSCAPE1
*Mood-Mania* impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts /excessive
energy
*Mood-mixed: *irritability/liability
*ANXIETY *
*Generalized anxiety sx *
( where when who/how long/how frequent
*Panic D/O-*
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
*OCD symptoms:*
checking/rituals/organizing rational vs irrational beliefs
*PTSD:*
nightmares, startle response/flashbacks/avoidance
*Social Anxiety Symptoms/Simple phobias*
*Psychosis*
*Hallucinations*
- Auditory/visual olfactory/tactile
*Paranoia*
*Delusions*
- TV,radio, thought broadcasting/referential thinking/
*Patient perceptions:*
spiritual beleifs/reality testing
*Other:* ADHD -hyperactivity Eating D/O.
*5)Past Psychiatric History:*
All psych illnesses/course/ past treatments hospitalizations. Medications used how long
a trial - Side effects problems with treatment. Past Suicide attempt
Identifying data - CORRECT ANSWER-patient's name, age, sex, marital status/
significant other, race, ethnicity, occupation
source and reliability - CORRECT ANSWER-clarify where the information came from
and how reliable the data are
chief complaint - CORRECT ANSWER-Patient's presenting condition in their own words
BRAINSCAPE1
, BRAINSCAPE1
The history of present illness definition - CORRECT ANSWER-the chronological
description of the evolution of the symptoms of the current episode
History of present illness: What to include - CORRECT ANSWER-*Chronological
description of the evolution of the symptoms of the current episode.
*Any changes that have occurred:* interests, relationships, behaviors, personal habits,
physical health.
*Ask open ended questions to get the info ("Can you tell me what brings you here
today?")
*Length of time that the current sx have been present
*Fluctuations of sx in severity or nature of sx over time?
*Presence of absence of stressors
*Factors that alleviate or exacerbate sx
*Has the person already sought treatment? (if so, who patient saw, what was done, how
often, modality, continuing treatment?)
Essential question to ask for the history of present illness interview - CORRECT
ANSWER-*What symptoms
*Severity of sx
*How long sx present
*Associated factors
*Why the patient is seeking help now?
*Triggering factors
*Setting in which the illness began (to understand etiology and significant contributions)
Psychiatric review of systems: Usefulness to patient interview - CORRECT ANSWER-
*Helps rule in/out diagnoses
*Identifies comorbid disorders
*Identifies other conditions that may be more bothersome to the patient, but not
identified
Psychiatric review of systems: four major categories - CORRECT ANSWER-MAPO
1)*Mood: depression
*SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor
agitation, suicidality)
*Mania: impulsivity, grandiosity, recklessness, excessive energy, talkativeness, racing
thoughts, hypersexuality
*mixed/other: irritability, liability
BRAINSCAPE1
CMN548 unit 1 Psychiatric history and
psychiatric assessment latest version
Elements of the psychiatric interview-2 - CORRECT ANSWER-patient history
(subjective info) and mental status exam (objective info)
Sadock -Complete psychiatric assessment - CORRECT ANSWER-1) *Identifying data*:
pt name.sex/,arital status/race/ethnicity/occupation.
*2) Source and reliability:* Where information is coming from (patient/chart/family) how
reliable information is- use own judgment
*3) Chief Complaint*: Pts own statement of why they are here>
*4)HPI History of present illness:* chronological description of current episode include
changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
*Include Psychiatric Review of Systems: *
Mood/anxiety/psychosis/other
*Mood- depressive symptoms*- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
BRAINSCAPE1
, BRAINSCAPE1
*Mood-Mania* impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts /excessive
energy
*Mood-mixed: *irritability/liability
*ANXIETY *
*Generalized anxiety sx *
( where when who/how long/how frequent
*Panic D/O-*
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
*OCD symptoms:*
checking/rituals/organizing rational vs irrational beliefs
*PTSD:*
nightmares, startle response/flashbacks/avoidance
*Social Anxiety Symptoms/Simple phobias*
*Psychosis*
*Hallucinations*
- Auditory/visual olfactory/tactile
*Paranoia*
*Delusions*
- TV,radio, thought broadcasting/referential thinking/
*Patient perceptions:*
spiritual beleifs/reality testing
*Other:* ADHD -hyperactivity Eating D/O.
*5)Past Psychiatric History:*
All psych illnesses/course/ past treatments hospitalizations. Medications used how long
a trial - Side effects problems with treatment. Past Suicide attempt
Identifying data - CORRECT ANSWER-patient's name, age, sex, marital status/
significant other, race, ethnicity, occupation
source and reliability - CORRECT ANSWER-clarify where the information came from
and how reliable the data are
chief complaint - CORRECT ANSWER-Patient's presenting condition in their own words
BRAINSCAPE1
, BRAINSCAPE1
The history of present illness definition - CORRECT ANSWER-the chronological
description of the evolution of the symptoms of the current episode
History of present illness: What to include - CORRECT ANSWER-*Chronological
description of the evolution of the symptoms of the current episode.
*Any changes that have occurred:* interests, relationships, behaviors, personal habits,
physical health.
*Ask open ended questions to get the info ("Can you tell me what brings you here
today?")
*Length of time that the current sx have been present
*Fluctuations of sx in severity or nature of sx over time?
*Presence of absence of stressors
*Factors that alleviate or exacerbate sx
*Has the person already sought treatment? (if so, who patient saw, what was done, how
often, modality, continuing treatment?)
Essential question to ask for the history of present illness interview - CORRECT
ANSWER-*What symptoms
*Severity of sx
*How long sx present
*Associated factors
*Why the patient is seeking help now?
*Triggering factors
*Setting in which the illness began (to understand etiology and significant contributions)
Psychiatric review of systems: Usefulness to patient interview - CORRECT ANSWER-
*Helps rule in/out diagnoses
*Identifies comorbid disorders
*Identifies other conditions that may be more bothersome to the patient, but not
identified
Psychiatric review of systems: four major categories - CORRECT ANSWER-MAPO
1)*Mood: depression
*SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor
agitation, suicidality)
*Mania: impulsivity, grandiosity, recklessness, excessive energy, talkativeness, racing
thoughts, hypersexuality
*mixed/other: irritability, liability
BRAINSCAPE1
