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13 Cards in this Set
- Front
- Back
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Interview Order
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GET PATIENT'S NAME
Introduction Demographics (age, occupation, marital status) HPI Psych ROS (10 min mark) PPsychHx FPsychHx PMH (18 min mark) PsoHx MSE (last five) |
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History of Present Illness
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What is your understanding of the condition that brought you to seek psychiatric care?
When did it begin? (If two, which one first?) How long did the symptoms persist? Why did you seek treatment at the time you did? Possible precipitants and stressors Are you currently in treatment? Inpatient, Outpatient, or Day Program? How are you doing now? |
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Psych ROS
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SIGECAP
S/HI DIGFAST A/VH; Paranoia; IOR, First Rank Symptoms OC ("Are you always running late because you check on things over and over?) GAD ("Are you a worrier?") Panic Symptoms Phobias Eating Disorder Substance Somatoform ("Have you had a lot of unexplained illnesses?") Cognitive Problems ADHD |
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Suicidal and Homicidal Ideation Questions
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Ever wished you were dead?
Every thought about killing yourself? How about now? Ever made an attempt on your life? Ever wished someone else was dead? Ever thought about killing someone? How about now? Ever made an attempt to kill someone? Any weapons or pills in the home? Stockpiles? What is the most violent thing you have ever done? |
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Substance Related Questions
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On the average day you have one drink, how many do you have?
How often do you drink alcohol? CAGE Many people experiment with illicit drugs. Have you Ever? Which ones? How often? CAGE (for each one) |
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Past Psychiatric History
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Past Diagnoses
When was the first episode? How many after? Was there ever a full recovery? When did you first seek treatment? Any identifiable precipitants or stressors? Past Somatic Treatments Outpatient Treatment Hospitalizations SI/HI/Attempts in the past Drug and Alcohol Treatment History What has worked best? Are you receiving any form of mental health care currently? Inpatient or Outpatient? |
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Family Psychiatric History
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Any blood relative been treated for a psychiatric disorder?
Diagnoses Somatic Treatments Outpatient Treatments Hospitalizations Family history of completed suicide What has worked best for them? |
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Past Medical History
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Are there any illnesses for which you are receiving treatment?
Ask: HTN, Thyroid, OCPs, Kidney, Diabetes Are you currently taking any prescription medications Are you taking any OTC medications? Are you taking any herbal remedies? Have you ever had a head injury that resulted in a LOC? Have you ever had a seizure? Are you currently allergic to any medications? Have you ever had a bad reaction to a psychiatric medication? |
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Somatoform ROS
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Any SOB when not exerting?
Any burning in your sexual organs or rectum? Any persistent lump in your throat? Any history of amnesia? Any daily vomiting episodes? Any daily pain in extremities regardless of activity? Any painful menses? |
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Past Social History
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B/R
Birth Order Intact Family? Parents' Occupation Relationship with family of origin Who lives at home? Relationship with current family Educational Level Marital History Employment History Legal History Military History Sexual Risk Factors (HIV RF) Traumatic and Abuse History Religion and role in life Disability? Who is your source of support? Who knows you best? Who is the most important person in your life? How have your psychiatric symptoms affected your life? |
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Five Minute Warning
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Check to make sure you have asked:
S/HI Depression / Mania Psychosis Substance HIV RF Abuse and Trauma History Follow-Up Questions to Pin Down Diagnosis THEN: MSE |
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Mental Status Examination
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Mood
MMSE 2x6 (<70); 2x24 (70-85); 2x48 (>85) Recall from MMSE Past four Presidents Similarities x 2; Proverb ("glass houses") Do you think you need treatment? How do other people see you right now? What will make all of this better? |
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Time Killer Questions
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What type of person do you think you are?
What do your friends and family like about you? What do you like about yourself? What do you do for fun? Describe for me a typical day… |
