Lyceum Northwestern University --

FQDMF College of Medicine

Dagupan City, Pangasinan

ASSIGNMENT:
Psychiatric History Outline

Submitted by:
GROUP 10, SECTION-B

Members:
SAVIO BELO TOU PINTO, Jelfy (Leader)
THOUDAM, Anurupa Devi
THOUDAM, Albert Singh
BODAPATI, Ajay Kumar
GARIMELLA, Gowthami

Submitted to:
Dr. Joy Tabanda Manzo, M.D.
March 12, 2021
PSYCHIATRIC INTERVIEW
I. Identifying Data
II. Source and reliability
III. Chief complaint
IV. Present Illness
V. Past Psychiatric history
VI. Substance Abuse
VII. Past Medical History
VIII. Family history
IX. Developmental & Social History
X. Review of Systems
XI. Mental Status Examination
XII. Physical Examination
XIII. Formulation
XIV. DSM V DIAGNOSIS
XV. Treatment Plan

I. IDENTIFYING DATA
 Name:
 Age:
 Sex:
 DOB:
 Marital status:
 Language
 Nationality
 religion
 Race
 Occupation:
 Educational attainment
 previous admissions to a hospital for the same or a different
condition
 with whom the patient lives
 Time of Admission:
 Date of Admission:

II. SOURCE AND RELIABLITY

 Name of informant (interviewed), age, living with patient or not
 Patient previous records or other records available
 Reliability
o depends on no. of sources and consistency of narrations
o could be rated as “good” or fair to poor
III. CHIEF COMPLAINT
 verbatim or according to patient’s own words
 according to who brought the patient

IV. HISTORY OF PRESENT ILLNESS

 chronological description of symptoms of the current episode
 Could also contain an account of patient’s behaviors, interest,
interpersonal relationships and physical health
 Length of symptoms presented, persistence or fluctuations
 Presence of stressors or no stressor at all
 Stressors could be at home, school or work, legal issues,
interpersonal difficulties or medical co morbidities
 Other factors that could alleviate or exacerbate symptoms like
coping, medications taken or external support or time of the day

V. PAST PSYCHIATRIC HISTORY

 extract all possible psychiatric illness of the patient and duration
 do they have the same symptoms such in the case of remission vs
relapse vs recurrence of illness
 Other symptoms that means a “comorbid condition is present”
 Medications taken before , dosage, side effects response to
medications & compliance
if consult done—what was the diagnosis
 Lethality History:
Past suicide history including ideation, intent, plan &
attempts, save potential, lethal notes giving away things and
death preparations
self-injurious behaviors, homicidal tendencies

VI. SUBSTANCE USE, ABUSE and ADDICTIONS

 nonjudgmental approach should be use
 type of substance use, routes, frequency, amount (cautious of
minimizing or denial)
 tolerance issues, withdrawal
 behavioral disturbances during intoxication or withdrawal
 effect of substance use at work, relationship & self-care
 may also include internet or gambling addictions, , eating disorders
 rehabilitation history or phase of rehabilitation done
 tobacco use

VII. PAST MEDICAL HISTORY

 account of medical illness, surgeries past & present & reaction to
illness, coping
 gives idea of potential cause of illness,
  helps in identifying confounding factors or comorbid conditions that
may affect treatment and prognosis of patients condition
 identify episodes of seizures, head injury & pain disorder
 reproductive history and menstrual history is important for women
 review of current medications - length of use compliance.
 review of nonpsychiatric medications or over the counter
medications
 History of allergies

VIII. FAMILY HISTORY

 important in determining genetic predisposition for mental illness or
helps in understanding formative psychosocial background
 Understand history of violence and suicide in the family, and
medical illness in the family
 familial response to medications
 HELPS IN IDENTIFYING POTENTIAL SUPPORT OR
STRESSORS IN THE FAMILY

IX. DEVELOPMENT and SOCIAL HISTORY

 reviews the stage of patient’s life
 important tool in determining major factors in the evolutions of the
disorder
 can identify the psychosocial stressors
 available information pertaining to prenatal of birthing history
 childhood history, school history and work history
 Military history if evident, legal history, marriage/ relationship
history
 smoker/alcoholic
 Diets
 sewage and waste disposal methods
 occupation
 drinking water consumption: eg:- mineral water
 how many hrs did he/ she sleeps

X. REVIEW OF SYSTEMS
 AIMS TO CAPTURE THE CURRENT MEDICAL OR
PSYCHOLOGICAL CONDITIONS
 attention should be focus on neurological or systemic conditions
XI. MENTAL STATUS EXAMINATION
 equivalent to PHYSICAL EXAMINATION IN MEDICINE
 assesses the mental functioning from the initial interaction till the
end of interview
 it gives a snapshot of patient’s mental status at the time of interview
 - General description
- Mood and Affect
- Speech
- Perception
- Thought
- Cognition
- Impulse control
- Judgment
- Insight

 GENERAL DESCRIPTION :
 Appearance and Behavior
o how the patients acts and looks during the interview
o style of dress, clothing, physical features, jewelries, grooming
and hygiene
o behavior and appropriateness
 Motor Activity
o was there any sign of restlessness, does your patient fidgets,
has tremors, shaky or any involuntary body movements -take
note of his manner of walking, unsteady gait which may point to
a neurologic condition
Observation skill is very important

 MOOD AND AFFECT:

 The patient stated he was miserable and conveyed a well-
communicated depressed affect.
 He was unable to respond to humorous comments, generally
displaying a restricted range of affect though he was at all times
appropriate.
 SPEECH:
 The patient had minimal speech and answered questions briefly,
displaying poverty of speech.
 When he did speak, his voice was soft and he spoke slowly with long
pauses. While the quantity of speech was reduced, the patient was
coherent”
o Production
o Spontaneity
o Coherence
o Slurred speech may point to a neurologic deficit
 THOUGHT:
 It is difficult to follow the patient’s stream of thought as he rapidly
jumped from one idea to the next, his thoughts are likewise organized
with looseness of association and neologisms. “ In the case of cats it is
always to be said. Why did you go?
  The patient firmly believes the KGB and CIA are plotting against him, to
kill him and ruin his business.
 In assessment of thought, take note of the following:
o content- paranoia, obsessions, nihilism, suicidal ideas,
pessimism
o flow of thought- “goal-directed”
o form of thought- any looseness of association
 PERCEPTION:
 the patient described auditory hallucinations that consisted of two male
voices that would argue with each other, comment on the patient’s
actions and command the patient to do things like “punch your brother.”
 They occurred frequently during the day, everyday, and on one
occasion the patient punched his brother in response.
 The patient often looked over his shoulder during the interview,
appearing to be responding to auditory hallucinations”
 COGNITION:
 Conscious state
 Attention and concentration
 Memory
 Abstraction ability
 Language function
 Attention and concentration
o example of test for: series of 7; spell WORLD backwards
 IMPULSIVITY:
 Is the patient capable of controlling sexual, aggressive and other
impulses
 Estimated from information in the patient’s recent history
 Behavior from the interview
 JUDGEMENT:
 Does the patient understand the likely outcome of his/her behavior?
 Can the patient predict what he or she would do in imaginary situations
 INSIGHT:
 Patient’s degree of awareness and understanding of being ill
 Levels of insight
o Complete denial
o Slight awareness of being sick
o Awareness of being sick but blaming it on others
 Intellectual insight
Symptoms and failures in social adjustment are due to
patient’s irrational feeling but without applying that to
future experiences
 True emotional insight
o Emotional awareness of the feelings and motives within the
patient and the important persons in his or her life which can
lead to basic changes in behavior
XII. Physical Examination:

 General Survey with vital signs:

 CR:
 O2 95% RA
 RR:
 Temperature:
 Blood pressure:
 Weight:
 Height:
 BMI:

 HENNT examination:
 Skin examination:
 Chest and lung examination:
 Cardiovascular examination:
 Abdomen and pelvic examination:
 Musculoskeletal and extremities examination:
 Neurological examination:

XIII. Formulation:
 Causes of the patient's psychodynamic breakdown-influences in the patient's
life that contributed to present disorder; environmental, genetic, and
personality factors relevant to determining patient's symptoms; primary and
secondary gains; outline of the major defense mechanism used by the
patient
 ICD-10 vs. DSM-5
 Additional psychiatric diagnostic studies
 Biopsychosocial approach and lab diagnosis
 Interviews with family members, friends, or neighbors by a social worker
  Psychological, neurological, or laboratory tests as indicated:
Electroencephalogram, computed tomography scan, magnetic
resonance imaging, tests of other medical conditions, reading
comprehension and writing tests, test for aphasia, projective or objective
psychological tests, dexamethasone-suppression test, 24-hour urine test
for heavy metal intoxication, urine screen for drugs of abuse.
XIV. DSM V DIAGNOSIS
 Diagnostic classification is made according to DSM-5. The diagnostic
numerical code should be used from DSM-5 or ICD-1 0. It might be prudent
to use both codes to cover current and future regulatory guidelines.

XV. Treatment Plan:

 Modalities of treatment recommended, role of medication, inpatient or
outpatient treatment, frequency of sessions, probable duration of therapy;
type of psychotherapy; individual, group, or family therapy; symptoms or
problems to be treated.
 Initially, treatment must be directed toward any life-threatening situations
such as suicidal risk or risk of danger to others that require psychiatric
hospitalization.
 Comprehensive treatment planning requires a therapeutic team approach
using the skills of psychologists, social workers, nurses, activity and
occupational therapists, and a variety of other mental health professionals,
with referral to self-help groups (e.g., Alcoholics Anonymous [AA]) if needed.
 If either the patient or family members are unwilling to accept the
recommendations of treatment and the clinician thinks that the refusal of
the recommendations may have serious consequences, the patient,
parent, or guardian should sign a statement to the effect that the
recommended treatment was refused.