OnExam

Identifying Information

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

Chief Complaint

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.

Mood Disorders

Depression - "SIGECAPS"
  • Low mood > 2 weeks
  • Sleep
  • Interest (anhedonia)
  • Guilt/worthlessness
  • Energy ↓
  • Concentration ↓
  • Appetite/weight change
  • Psychomotor slowing/agitation
  • Suicide: thought/plan/access
Mania - "GIDDINESS"
  • Grandiose
  • Increased activity (goal directed/high risk)
  • Decreased judgment
  • Distractible
  • Irritability
  • Need less sleep
  • Elevated mood
  • Speedy talking
  • Speedy thoughts

Anxiety Disorders

Generalized Anxiety Disorder
  • Excessive anxiety and worry that is difficult to control
  • Restlessness (feeling “on edge” or “wound up”)
  • Fatigue
  • Concentration ↓
  • Irritability
  • Muscle tension
  • Sleep problems
Social Phobia (Social Anxiety Disorder)
  • Fear/avoidance of social performance situations
  • Anticipates embarrassing oneself in social situations
  • Hypersensitive to criticism
  • May precipitate panic attacks
Specific Phobia
  • May include animals, heights, blood/infection, flying, etc.
Panic disorder with/without agoraphobia

Panic attacks may include:
  • 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
  • Derealization/depersonalization
  • Fear of dying, losing control, going crazy
  • Chills or hot flashes
  • Paresthesias
Obsessive-compulsive disorder (OCD)
  • 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
Post-traumatic stress disorder (PTSD)
  • Recurrent, intrusive recollections of the trauma
  • Nightmares of the event
  • Avoidance of stimuli associated with the trauma
  • Illusions, hallucinations, dissociative “flash-backs”
  • Sleep difficulties
  • Irritability
  • Decreased concentration
  • Hypervigilance
  • Startles easily
  • Anhedonia, detachment from others, restricted range of affect

Psychosis

  • Positive symptoms
    • Hallucinations
    • Delusions
  • Negative symptoms
    • Flattened affect
    • Anhedonia
    • Avolition
    • Alogia
    • "Thought blocking"
  • Disorganization
    • Thinking
    • Speech
    • Behaviour
  • Cognitive symptoms
    • Memory impairment
    • Attention difficulties
    • Deficits in processing information
  • Catatonic symptoms
    • Posturing
    • Excess motor activity
    • Rigidity
    • Stupor

Eating Disorders

  • Binging/ purging/ restrictions/ amenorrhea
  • Perception of body image or weight

Attention-Deficit/Hyperactivity Disorder

  • Inattention
    • 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
  • Hospitalizations
  • Legal history

Family History (FmHx)

  • History of major psychiatric illness (e.g. schizophrenia, major depression)
  • Attempted or completed suicide

Social History (SocHx)

  • Occupation/Education
  • Relationship Status and sexual orientation
  • Establish the history of past housing as appropriate
  • Sources of support and coping mechanisms

Substance Use History (SubHx)

Medications

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
    • Amphetamines

Allergies

Note allergies and ensure they concord with those listed in the patient's record.

Immunizations

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.

References

  1. Interviewing and assessment. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 17-56.
  2. 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.
  3. http://www.bcmj.org/article/initial-psychiatric-assessment-practical-guide-clinical-interview. Accessed March 4, 2011.
  4. Levinson A & Young LT. Assessment of patients with bipolar disorder. In: Goldbloom D, ed. Psychiatric Clinical Skills. Philadelphia, PA: Elsevier Mosby; 2006: 51-69.
  5. 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.
  6. Williams J, Noël P, Cordes J, et al. Is this patient clinically depressed? JAMA 2002;287(9):1160-1170.
  7. Mood disorders. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 139-165.
  8. Anxiety disorders. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 167-200.
  9. Menezes N & Zipursky R. Assessment of patients with psychosis. In: Goldbloom D, ed. Psychiatric Clinical Skills. Philadelphia, PA: Elsevier Mosby; 2006: 29-49.
  10. Diagnosis and classification. In: Andreasen N & Black D. Introductory Textbook of Psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2006: 3-15.