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6 Cards in this Set

  • Front
  • Back
a. Introduce yourself

b. State what you are

c. Say who sent you

d. Say why you are there

e. Give a time frame

Example: "Hello, Ms./Mr./Mrs. ____, I'm a medical student, working with Dr. ____. He/she asked me to come in and get some basic information about what brought you here. I have about forty-five minutes to talk now, but I can come back later and talk if we need more time."
11 steps of psychiatric interview
1. Introduction
2. Chief Complaint
3. History of Present Illness
4. Developmental/Social History
5. Past Medical History
6. Family History
7. Review of Systems
8. Mental Status Exam
9. Formulation
10. Diagnoses
11. Treatment plan
7 content items of psych HPI
Location: "where" is the problem in the patient's life
Quality: What is the problem like?
Severity: How bad is the problem?
Timing: When does it occur? Is there a particular time of day or situation when the problem is better or worse?
Context: What sort of situations will bring the problem on?
Modifying factors: Is there anything that makes it better or worse? Has the patient tried anything to help?
Associated features: Is there anything else associated with the problem.
Elements of Developmental/Social History:
a. Social context: This includes many factors, such as marriage, family, occupation, living situation, and environmental stressors.

b. Development: Developmental issues such as history of traumatic events, childhood neglect, and other traumas are important.

c. Education

d. Military service
elements of mental status exam
a. Appearance
b. Behavior
c. Speech
d. Mood
e. Affect:
f. Thought process
g. Thought content
h. Cognition
i. Insight
j. Judgement
axes of psych diagnosis
a. Axis I: Major mental illness diagnoses (e.g., major depression, panic disorder, etc.)

b. Axis II: Personality and developmental disorder diagnoses

c. Axis III: Physical illnesses

d. Axis IV: Stressors

e. Axis V: Estimation of the current level of functioning