Current clinical strategies : psychiatry

I. Psychiatric History A. Identifying information. Age, sex, marital status, race, referral source. B. Chief complaint (CC). Reason for consultation; the reason is usually a direct quote from the patient. C. History of present illness (HPI) 1. Current symptoms: date of onset, duration and course of symptoms. 2. Previous psychiatric symptoms and treatment. 3. Recent psychosocial stressors: stressful life events that may have contributed to the patient's current presentation. 4. Reason the patient is presenting now. 5. This section provides evidence that supports or rules out relevant diagnoses. Therefore, documenting the absence of pertinent symptoms is also important. 6. Historical evidence in this section should be relevant to the current presentation. D. Past psychiatric history 1. Previous and current psychiatric diagnoses. 2. History of psychiatric treatment, including outpatient and inpatient treatment. 3. History of psychotropic medication use. 4. History of suicide attempts and potential lethality. E. Past medical history 1. Current and/or previous medical problems. 2. Type of treatment, including prescription, overthe- counter medications, home remedies. F. Family history. Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse. G. Social history 1. Source of income. 2. Level of education, relationship history (including marriages, sexual orientation, number of children); individuals who currently live with patient. 3. Support network. 4. Current alcohol or illicit-drug usage. 5. Occupational history. H. Developmental history. Family structure during childhood, relationships with parental figures and siblings; developmental milestones, peer relationships, school performance. II. Mental Status Exam. The mental status exam is an assessment of the patient at the present time. Historical information should not be included in this section. A. General appearance and behavior 1. Grooming, level of hygiene, characteristics of clothing. 2. Unusual physical characteristics or movements. 3. Attitude. Ability to interact with the interviewer. 4. Psychomotor activity. Agitation or retardation. 5. Degree of eye contact. B. Affect 1. Definition. External range of expression, described in terms of quality, range and appropriateness. 2. Types of affect a. Flat. Absence of all or most affect. b. Blunted or restricted. Moderately reduced range of affect. c. Labile. Multiple abrupt changes in affect. d. Full or wide range of affect. Generally appropriate. C. Mood. Internal emotional tone of the patient (ie, dysphoric, euphoric, angry, euthymic, anxious). D. Thought processes 1. Use of language. Quality and quantity of speech. The tone, associations and fluency of speech should be noted. 2. Common thought disorders a. Pressured speech. Rapid speech, which is typical of patients with manic disorder. b. Poverty of speech. Minimal responses, such as answering just “yes or no.” c. Blocking. Sudden cessation of speech, often in the middle of a statement. d. Flight of ideas. Accelerated thoughts that jump from idea to idea, typical of mania. e. Loosening of associations. Illogical shifting between unrelated topics. f. Tangentiality. Thought that wanders from the original point. g. Circumstantiality. Unnecessary digression, which eventually reaches the point. h. Echolalia. Echoing of words and phrases. i. Neologisms. Invention of new words by the patient. j. Clanging. Speech based on sound, such as rhyming and punning rather than logical connections. k. Perseveration. Repetition of phrases or words in the flow of speech. l. Ideas of reference. Interpreting unrelated events as having direct reference to the patient, such as believing that the television is talking specifically to them. E. Thought content 1. Definition. Hallucinations, delusions and other perceptual disturbances. 2. Common thought content disorders a. Hallucinations. False sensory perceptions, which may be auditory, visual, tactile, gustatory or olfactory. b. Delusions. Fixed, false beliefs, firmly held in spite of contradictory evidence. i. Persecutory delusions. False belief that others are trying to cause harm, or are spying with intent to cause harm. ii. Erotomanic delusions. False belief that a person, usually of higher status, is in love with the patient. iii. Grandiose delusions. False belief of an inflated sense of self-worth, power, knowledge, or wealth. iv. Somatic delusions. False belief that the patient has a physical disorder or defect. c. Illusions. Misinterpretations of reality. d. Derealization. Feelings of unrealness involving the outer environment. e. Depersonalization. Feelings of unrealness, such as if one is “outside” of the body and observing his own activities. f. Suicidal and homicidal ideation. Suicidal and homicidal ideation requires further elaboration with comments about intent and planning (including means to carry out plan). F. Cognitive evaluation 1. Level of consciousness. 2. Orientation: Person, place and date. 3. Attention and concentration: Repeat five digits forwards and backwards or spell a fiveletter word (“world”) forwards and backwards. 4. Short-term memory: Ability to recall three objects after five minutes. 5. Fund of knowledge: Ability to name past five presidents, five large cities, or historical dates. 6. Calculations. Subtraction of serial 7s, simple math problems. 7. Abstraction. Proverb interpretation and similarities. G. Insight. Ability of the patient to display an understanding of his current problems, and the ability to understand the implication of these problems. H. Judgment. Ability to make sound decisions regarding everyday activities. Judgement is best evaluated by assessing a patient's history of decision making, rather than by asking hypothetical questions. III. DSM-IV Multiaxial Assessment Diagnosis Axis I: Clinical disorders Other conditions that may be a focus of clinical attention. Axis II: Personality disorders Mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning IV. Treatment plan. This section should discuss pharmacologic treatment and other psychiatric therapy, including hospitalization. V. General medical screening of the psychiatric patient. A thorough physical and neurological examination, including basic screening laboratory studies to rule out physical conditions, should be completed. A. Laboratory evaluation of the psychiatric patient 1. CBC with differential. 2. Blood chemistry (SMAC). 3. Thyroid function panel. 4. Screening test for syphilis (RPR or MHA-TP). 5. Urinalysis with drug screen. 6. Urine pregnancy check for females of childbearing potential. 7. Blood alcohol level. 8. Serum levels of medications. 9. Hepatitis C testing in at-risk patients. 10. HIV test in high-risk patients. B. A more extensive work-up and laboratory studies may be indicated based on clinical findings.