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PSYCHIATRIC ASSESSMENT - Coggle Diagram
PSYCHIATRIC ASSESSMENT
1) Chief Complaint
quotation + objective statement
2) HPI
include safety elements: suicidal/homicidal ideation
COLDERA + Timing & Severity = "OLDCARTS"
3) Psychiatric History
previous symptoms/diagnoses (age of onset, number of episodes, last episode)
previous medications used and responses
other treatments (psychotherapy, ECT/TMS)
psychiatric/rehab hospitalizations
suicide attempts/other self harm episodes
harm towards others
abuse/mistreatment experienced
4) Substance Use History
tobacco and other drugs (age of first use, overall use pattern, specific use pattern over the past year, date of last use)
5) Medical History
"MIDAS" (medications, illness history, primary care doctor, allergies, surgical history)
7) FHx
history of mental health diagnoses in relatives
history of mental health treatment and response in relatives (ECT, TMS)
history of suicide completions or attempts in relatives
6) ROS
brief (young, healthy, middle/upper class; statistically fewer medical problems & good follow up with doctors)
full (elderly, chronically mentally ill; statistically more medical problems and poor follow up with doctors)
8) Social Hx
current marital status/previous marriages
children
home life, others in home, pets
current job or financial status
education level
legal issues (past and current)
military experience
religious beliefs
9) Psychiatric ROS
confirms DSM-V criteria for symptoms pt is experiencing
use broad screening questions (2) for each category
negative --> move on to next category
positive --> probe further until you can confirm diagnosis & have obtained relevant symptoms
"depressed patients sound anxious, so claim psychiatrists" = depression/other mood disorders, psychotic disorders, substance abuse disorders, anxiety disorders, somatic disorders, cognitive disorders, personality disorders
10) Mental Status Exam
appearance (hair, facial hair, face, eyes, body, movements, clothes)
behavior and attitude (friendliness, cooperativeness, engagement, sitting, pacing, standing, lying)
speech (rate, volume, latency of response, articulation, general quality)
affect (clinicians impression of pts emotional state; stability, appropriateness, range and intensity of affect)
mood (pts report of their mood)
thought process (coherence, sequentiality, logic of thought)
thought content (suicidal/homicidal ideation, psychotic ideation, themes)
MSK (tremors, overall strength, gait)
cognitive examination (level of awareness or wakefulness, attention and concentration, memory, orientation, knowledge
insight (understanding of illness, knowledge of having an illness, conception of causes and treatments)
judgment (seeking help when needed, making decisions to not put self in danger or protect themselves)
11) Physical Exam
neurologic exam very important, other systems depend on the pt encounter
history of trauma may preclude sensitive examinations
12) Biopsychosocial Formulation
formulation that accounts for the various factors that lead to the pts presentation and make a plan for the future