Scribd Logo
Upload

Welcome to Scribd!

  • 2 views

    Psych HX and MSE PDF

    Uploaded by

    leatherpowerbank

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Psych HX and MSE PDF

    Uploaded by

    leatherpowerbank
    2 views4 pages

    Original Title

    Psych HX and MSE (pdf) (1)

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2 views4 pages

    Psych HX and MSE PDF

    Uploaded by

    leatherpowerbank

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    PSYCHIATRIC HISTORY TAKING AND MENTAL STATUS EXAMINATION.

    HISTORY.

    Biodata: Name, age sex, marital status, occupation, address, ethnicity, religion.

    Referral source and reason for referral.

    Source of history and reliability of source. Other sources of history.

    Presenting complaint (× duration): A short phrase paraphrasing the patient e.g. feelings of
    depression or directly quoting the patient.

    History of presenting complaint: A chronological description of the development of the


    presenting complaint. Associated factors to the presenting complaint including important
    factors not present. Functional impairments. Review of psychopathological systems
    ( symptoms of a mood, anxiety or psychotic disorder not already stated above). Premorbid
    personality.

    A useful rubric would be to: (1). Clerk the PC; (2). Clerk factors associated with the PC; (3). Rule
    out other important differentials; (4). Rule out complications (functionality).

    Remember to always describe an episode or episodes, past or present, when doing the HPC.
    This would apply to the PC itself (and its associated features) and to the review of systems. An
    episode is a group of symptoms occurring during the same time period. It is a time limited
    description of co-occuring features describing an illness. An episode could be long (e.g., more
    than 6 months, 2 years or more) or brief (e.g., 30 minutes when describing a panic attack). It
    could be single or recurring. If recurring, describe frequency.

    Past psychiatric history: Past contact with mental health services including counselors,
    psychologists, psychiatrists with dates, treatment, duration of treatment or intervention and
    reasons for termination. Past admissions to psychiatric wards or institutions including
    diagnoses, dates, length of stay, follow-ups. Treatments and compliance with treatments.
    Reasons for non-compliance. Past history of suicide attempts.

    Medical history: Particularly DM, HTN, epilepsy, thyroid disorders, HIV, CVA, Autoimmune
    disorders (SLE), significant head trauma, cerebral tumours, renal failure, liver failure, cardiac
    disorders. Medical treatments like steroid therapy, methyldopa, thyroxine etc. Relevant
    surgeries.

    Substance use history: Particularly alcohol, cannabis, cocaine, marijuana, OTC and
    prescribed medication. When and how did it start? (peer/family influence, stressors etc). How
    did it progress? (tolerance). How long have they been taking the substance in total and how
    long have they been taking the greatest and or most recent dose? Temporal relationship
    between substance use and mood, anxiety, psychotic or cognitive symptoms. Withdrawal
    symptoms? Has the patient ever tried to stop but failed? Are there occupational or other social
    consequences to the use of the substance (negative consequences)? Insight into substance
    use.

    Family history of psychiatric disorders: Particularly immediate family including parents,


    siblings and children followed by extended family (aunts, uncles, cousins, etc). Diagnoses.
    Treatments. Admissions. Interventions. Anecdotal reports of abnormal behavior in family
    members. Family history of suicide attempts. Family history of substance use.

    Personal and family history:

    • Marital status of parents when conceived? Planned/wanted pregnancy? Maternal


    illnesses during pregnancy? Maternal substance use during pregnancy? Significant
    social stressors for mother during pregnancy?

    • Normal spontaneous vaginal delivery? Preterm birth? Prolonged labour? Assisted


    delivery? Complicated delivery? Emergency CS? Delayed first breath? Low birth
    weight? Neonatal jaundice? Prolonged post-birth hospital stay?

    • Developmental milestones (crawl, walk, talk)? Childhood illnesses and hospital stays?

    • Placement amongst siblings and step-siblings (e.g. 3rd of 4 children for both parents
    with 2 paternal step-siblings and 3 maternal step-siblings). Parents current marital
    status if both still alive? Input of each parent in patient’s life (emotionally, physically).
    Relationship with parents and siblings. Living situation. Members of household. Type of
    abode.

    • Current level of educational attainment and academic performance (e.g. tertiary


    education in engineering, A – student). Schools attended with relevant school changes.
    If currently still in school, attitude towards school work, relationship with teachers and
    classmates. Grades/subjects etc.

    • Current employment if working? Satisfaction with work and remuneration from work?
    Relationship with coworkers, superiors and subordinates. Employment history if
    relevant.

    • Relationship history. Number, duration and quality of relationships. Quality of current


    relationship if in one.

    • Sexual history. Age of first coital act if sexually active. Sexual orientation. Risky sexual
    behavior. History of childhood sexual abuse. Rape? Attitude towards sex (sacred,
    conquest etc).

    • Legal history. Arrests/detentions and reasons for them, protection/restraining orders


    against patient.
    MENTAL STATUS EXAMINATION.

    General appearance: Describe as a novelist might. Particular attention to body hygiene,


    grooming and dressing. Mannerisms. Calm, restless, agitated, aggressive.

    Attitude towards examiner: Cooperative/uncooperative. Engaging/suspicious/guarded/


    defensive. Good eye contact/poor eye contact.

    Psychomotor activity and speech: Normal psychomotor activity, psychomotor retardation,


    psychomotor agitation. Normal, slow, fast speech. Normal, decreased, increased volume of
    speech. Monotonous/prosodic speech. Normal articulation/stuttering, vocal tics, dysarthrias.

    Mood and affect: Mood as described by patient. Euthymic if normal. Affect – congruent/
    incongruent; restricted/constricted/blunt/flat; labile; shallow/full.

    Perceptual disturbances: hallucinations in all sensory modalities, derealisation,


    depersonalization.

    Thought:

    • Process: Spontaneity (disinhibited, spontaneous, hesitant); production of ideas (poverty


    of ideas, normal, overabundance of ideas); flow of ideas (slow, normal, fast, flight of
    ideas); rational/irrational; relevant/irrelevant; goal-directed/circumstantial/tangential/
    loosening of associations/clang associations; incomprehensible/incoherent/neologisms/
    word salad (reflecting disordered mentation, report only if present)

    • Content: Suicidal ideation, homicidal ideation, delusions (persecutory, grandiose,


    thought insertion, thought withdrawal, thought broadcasting etc), obsessions, phobias.

    Cognition: Level of consciousness and alertness, orientation in time, place and person,
    attention and concentration, registration and recall, short term, intermediate and long term
    memory, fund of knowledge, abstract thinking.

    Judgment: Test judgment – hypothetical question.

    Insight: No insight/partial insight/intellectual insight/full insight.

    PHYSICAL EXAMINATION

    Vitals: Pulse, Blood pressure, Respiratory Rate, Temperature, Diascan.

    General examination: Painful/respiratory distress, moist mucous membranes, pallour, icterus,


    febrile to touch.

    Cardiovascular system: S1/S2 murmurs.


    Respiratory system: Bronchovesicular breath sounds, added sounds.

    Abdomen: flat/full/distended, soft/firm/hard, non-tender/tender, ± rebound, ± organomegally,


    bowel sounds.

    Central nervous system: Level of consciousness, GCS, muscle wasting, fasciculations, tone/
    power/reflexes in all limbs.

    Musculoskeletal system.

    INVESTIGATIONS

    Bloodwork: CBC, U & Es, LFTs, TFTs, HIV, FBS, FLP, VDRL, ESR.

    Others: ECG, ± CXR, ± CT brain, ± EEG.

    You might also like