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Primary Care Psychiatry
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Primary Care Psychiatry
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Primary Care Psychiatry, 2nd Edition TEST BANK byRobert McCarron, Glen Xiong
Identifying data - ANSWER:Specific information: name, age, race, religion, education,
marital status, employment, address.
- need two identifiers: confidentiality standards of practice, make sure your pt is who
they say they are and documenting that.
Chief Complaint - ANSWER:C/O: pts own words of why they are seeing you, briefly
stated.
-It is part of the evaluation of a persons thought process as well.
Answers should be consistent with being in your office, not concrete to the question
asked.
Organic - ANSWER:Any disease associated w/ detectable or observable changes in
one or more body organs.
Concrete thinking - ANSWER:- a very literal way of thinking.
- is a sign of cognitive impairment, if it isn't part of a developmental disorder,
dementia or other organic insult must now enter your differential. At this point a
family member of friend should be present to continue interview and validate
information.
HPI - ANSWER:- Onset of current symptoms: acute or gradual, in response to event
or in isolation, any new physical/medical issues associated with onset. Is this a new
phenomena?
- Severity or changes in symptoms since onset: rate 1-10. When was your last "good
day"?
- Presence of suicidal ideation or intent, is there a plan, what is the possibility of
follow through.
- Any changes in living situation or life events?
- Any new meds prescribed or OTC?
- Any change is substances of abuse once used for recreation?
- What if any is the change LOF.
SIG E CAPS - ANSWER:Sleep
Interest( change in daily enjoyable activities)
Guilt (or worry)
energy (too much or too little),
concentration
appetite
psychomotor changes (agitated or slowed) suicidal ideation
, Previous Psych Hx - ANSWER:- First presentation and symptoms. Identify specific
precipitant.
- Tx and recurrence rate.
- Hospitalizations and precipitants.
- Hx of suicidal ideation or attempts.
- Medication hx, benefits, side effects, reasons for stopping.
- Past hx substance abuse.
- Hx of trauma.
A denial of a past hx does not negate hx of illness, it may just negate hx of treatment
Past Medical Hx - ANSWER:Information will help with Ddx
- Loss of consciousness, head aches or visual changes
- Endocrine issues: menstrual irregularity, ejaculatory difficulty, changes in hair, skin
or weight
- Head injuries at any time in life.
- seizure disorders or convulsions or "loss of time"
-Pregnancies, full term or early termination.
- Sexual activity and practice: current and past.
- All surgeries or prolonged illnesses that effected lifestyle, especially with childhood
onset.
Medication hx - ANSWER:- list all meds, the dosage, time of day taken, and when
med was started.
- verify how and why the med was prescribed.
- include OTCs, vitamins and sups (DDI's)
Family Hx - ANSWER:Maternal and paternal history
Psychiatric history and treatment
Substance abuse history
Any history of suicides
Any history of abuse
Social Hx - ANSWER:Childhood history
Education history
Developmental delays or issues appropriate to the subject of the assessment
Occupational or work history
Relationship history including domestic abuse
Religious or spiritual beliefs and values
Family structure, proximity and perceived support
Legal issues
collection of symptoms - ANSWER:- Symptoms are the subjective experience of a
person. How they are experiencing the illness state. It begins in the chief complaint.
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