1.

CC and Hx
I. Identifying data
a. Name
b. Age
c. Sex
d. Demographics
e. Referral details
II. Chief Complaint
III. History of present illness
 Comprehensive account of cc together with associated symptoms
 Chronological account of main problem and symptoms
o When problem started
o How problem progressed
o What is happening to problem now
 Main problem
o Details of emergence of first symptoms
o Nature and severity of stressors
o Presence or absence of common psychiatric symptoms
 Effect of the illness on the patient’s life (work, social relations, ability to care for
self)
 Treatment (biological agents and doses, where and by whom treatment has
been given)
 Relationship of the psychological illness to current medical status
IV. Past psychiatric history
 Previous episodes of illness
 Past psychiatric admissions and treatments received
 Outpatient treatment (psychotropic drugs or psychotherapy)
V. Past Medical History
 Neurological disease or other medical conditions
 Comprehensive medication list
VI. Family history
 Parents
 Family size, birth order, special relationships, family atmosphere, tension and
stress
 Family history of psychiatric illness, including alcoholism and suicide attempts
VII. Personal history (anamnesis)
a. Early developmental (complications)
i. Prenatal and perinatal (normal delivery/premature/CS)
b. Childhood
c. School academic performance
d. Adolescence
e. Adulthood
i. Occupational History
ii. Religion
iii. Menstrual history
iv. Sexual history
v. Marital/relationship history
 vi. Children
vii. Military History (ptsd)
viii. Educational history
ix. Forensic history/Legal history
x. Habits
xi. Leisure
xii. Social network
xiii. Current living situation

2. Mental Status Exam

I. General appearance
a. Objective observation (male/female etc)
b. Age (does he look like his age (depressed or under subs abuse look older)
c. Hygiene (well-dressed/dishevelled, +/- malodorous (homeless, schizophrenia,
dementia, state of clothes, facial hair, nails)
d. Eye contact (good/poor/darting)
e. Built (tall/short, obese/thin)
f. Posture (how he is when being interviewed, lying in bed, sitting, cross-legged, moves
legs a lot)
g. Facial expression (smiling, suspicious, tensed from anxiety)
h. Level of consciousness (awake and alert, hypervigilant, drowsy)
II. Behavior
a. Behaviour (cooperative/not cooperative, suspicious, paranoid)
b. Motor activity (psychomotor agitation/retardation)
c. Abnormal movements (tremors, dystonia, tics; acute/chronic)
d. Gait (normal, shuffling, ataxic)
III. Speech and language
a. Rate (normal, slow, rapid, pressured, mutism)
b. Flow (spontaneous, delay in initiation, stuttering after initiation)
c. Intensity (loud, soft, depressed)
d. Comprehension (ask one-, two-, three- step command, point on body part, hold pen
etc)
e. Repetition of language (preservation, echolalia)
f. How patient name things
g. Reading
h. Writing
IV. Mood and affect
a. Mood (px subjective report of his feelings) – angry, sad, frustrated, worried
Is the mood congruent to his affect?
b. Affect (your objective report)
i. Range (full, restricted, labile)
ii. Intensity (normal, flat, constricted, heightened)
V. Thought process
a. Clarity (coherent/incoherent, logical/illogical)
b. Flow/associations (goal-directed, circumstantial, tangential, flight of ideas, loose
associations, word salad, racing thoughts, thought blocking)
VI. Thought content
a. Hallucinations
 i. Auditory (command? 1/more voices? m/f? someone you know? Heard
inside/outside head?)
ii. Visual (dark shadows/human figure)
iii. Olfactory
iv. Somatic
b. Delusions
i. Prosecutor
ii. Grandiose
iii. Somatic (eg parasitism)
iv. Erotomania
v. Idea of reference
Collaboration with family important
c. Obsessions (anxiety, OCD)
i. How do they deal?
ii. Is it associated with compulsion to relieve
d. Phobias
VII. Cognition
a. Orientation
i. Time
ii. Place
iii. Person
iv. Season
v. Date, month, year
vi. Where you are
b. Attention (ability to focus)
i. Ask to repeat digits (1, 2, 3 digit numbers)
c. Concentration (ability to sustain attention)
i. Serial 7s (consider educational background/old age)
ii. Months of year backward
iii. Spell backward
d. Memory
i. Short term (recall 3 words after 5 minutes)
ii. Long term
1. Episodic: important events in life (confirm with fam)
2. Semantic: general info, presidents, country capitals
e. Abstraction (abstract/concrete thinking)
i. What brought you to hospital/clinic? (may answer transportation or
symptoms)
ii. proverbs
iii. test if they comprehend beyond meaning
f. constructional and visuospatial ability (draw a clock/cube)
VIII. insight/judgment
a. insight – px understanding of symptoms, diagnosis, admission to clinic, and impact
on them and daily functioning (including relationships, jobs, legally)
b. judgment – px decision or action with condition and daily activities
i. what would you do if you find a stamped, addressed letter in the street?

3. Differential diagnosis and final diagnosis

 You can use DSM-V for criteria to rule in or out

4. Management
5. Related research (Like other possible therapy for the diagnosis, new medications to treat so etc)