Gather the patient's general identifying data.
Pertinent basic information:
- If obtaining collateral history from someone other than the patient, indicate the reliability of the other informant(s)
- Route of referral
Elicit the patient's chief complaint or reason for visit/encounter.
History of Presenting Illness (HPI)
Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.
- Low mood > 2 weeks
- Interest (anhedonia)
- Energy ↓
- Concentration ↓
- Appetite/weight change
- Psychomotor slowing/agitation
- Suicide: thought/plan/access
- Increased activity (goal directed/high risk)
- Decreased judgment
- Need less sleep
- Elevated mood
- Speedy talking
- Speedy thoughts
Generalized Anxiety Disorder
Social Phobia (Social Anxiety Disorder)
- Excessive anxiety and worry that is difficult to control
- Restlessness (feeling “on edge” or “wound up”)
- Concentration ↓
- Muscle tension
- Sleep problems
- Fear/avoidance of social performance situations
- Anticipates embarrassing oneself in social situations
- Hypersensitive to criticism
- May precipitate panic attacks
Panic disorder with/without agoraphobia
Panic attacks may include:
- May include animals, heights, blood/infection, flying, etc.
Obsessive-compulsive disorder (OCD)
- Shortness of breath
- Palpitations, pounding heart, or accelerated heart rate
- Sweating, trembling, shaking
- Feeling of choking
- Chest pain/discomfort
- Feeling nauseated, dizzy, faint, lightheaded
- Abdominal discomfort
- Fear of dying, losing control, going crazy
- Chills or hot flashes
Post-traumatic stress disorder (PTSD)
- Obsession: a recurrent and persistent idea, thought, impulse, or image that is experienced as intrusive and inappropriate that causes marked anxiety/distress . Themes include aggression, contamination, symmetry, sexuality, hoarding, religion, somatic/appearance/body
- Compulsion: a repetitive, intentional behaviour performed in response to the obsession. Repetitive hand washing, checking, counting, praying
- Recurrent, intrusive recollections of the trauma
- Nightmares of the event
- Avoidance of stimuli associated with the trauma
- Illusions, hallucinations, dissociative “flash-backs”
- Sleep difficulties
- Decreased concentration
- Startles easily
- Anhedonia, detachment from others, restricted range of affect
- Positive symptoms
- Negative symptoms
- Flattened affect
- "Thought blocking"
- Cognitive symptoms
- Memory impairment
- Attention difficulties
- Deficits in processing information
- Catatonic symptoms
- Excess motor activity
- Binging/ purging/ restrictions/ amenorrhea
- Perception of body image or weight
- Often makes careless mistakes
- Difficulty sustaining attention
- Listening difficulties
- Difficulty organizing tasks and activities
- Avoids attention-heavy tasks
- Looses important items (e.g., keys, wallet, mobile phone)
- Hyperactivity and Impulsivity
- Fidgets with hands and feet
- Trouble remaining seated when expected
- Runs and climbs in inappropriate situations
- Unable to participate in leisurely activities
- Unable to be still for extended periods of time
- Talks excessively
- Trouble waiting for talk in conversation
- Trouble waiting for turn
- Interrupts or intrudes on others
Past Medical History (PMHx)
- Past psychiatric diagnoses and non psychiatric illnesses (any neurological history)
- Past treatment/medications including side effects, effectiveness, and compliance
- Violence, suicidal/homicidal ideation & attempts
- Legal history
Family History (FmHx)
- History of major psychiatric illness (e.g. schizophrenia, major depression)
- Attempted or completed suicide
Social History (SocHx)
- Relationship Status and sexual orientation
- Establish the history of past housing as appropriate
- Sources of support and coping mechanisms
Substance Use History (SubHx)
Gather complete list, including relevant drugs such as:
- Psychometric medications (e.g. antidepressants, anxiolytics)
- Pain medications/analgesics
- Other psychiatric drugs
- Past or present use of phenothiazines
Note allergies and ensure they concord with those listed in the patient's record.
Note immunizations and ensure they are up to date in the patient's record.
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
- Interviewing and assessment. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 17-56.
- Lin D, Martens J, Majdan A, et al. Initial psychiatric assessment: a practical guide to the clinical interview. British Columbia Medical Journal 2003;45(4):172-173. http://www.bcmj.org/article/initial-psychiatric-assessment-practical-guide-clinical-interview. Accessed March 4, 2011.
- Levinson A & Young LT. Assessment of patients with bipolar disorder. In: Goldbloom D, ed. Psychiatric Clinical Skills. Philadelphia, PA: Elsevier Mosby; 2006: 51-69.
- Carlat, D. The psychiatric review of symptoms: a screening tool for family physicians. Am Fam Phys. 1998;58(7):1617-1626. http://www.aafp.org/afp/981101ap/carlat.html. Accessed March 4, 2011.
- Williams J, Noël P, Cordes J, et al. Is this patient clinically depressed? JAMA 2002;287(9):1160-1170.
- Mood disorders. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 139-165.
- Anxiety disorders. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 167-200.
- Menezes N & Zipursky R. Assessment of patients with psychosis. In: Goldbloom D, ed. Psychiatric Clinical Skills. Philadelphia, PA: Elsevier Mosby; 2006: 29-49.
- Diagnosis and classification. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 3-15.