CMN 548 Module 1 study guide
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1. GUIDE SADOCK Complete the following table which outlines the elements
Chapter 7.1 - 7.2, of the initial psychiatric
7.6 interview:
2. Identifying data Name, age, sex, marital status, religion, education, ad-
Topic dress, phone number, occupation, source of referral
3. Identifying data Be direct in obtaining identifying data. Request specific
Questions answers.
4. Identifying data If patient cannot cooperate, get information from family
Comments and member or friend; if referred by a physician, obtain med-
helpful hints ical record.
5. Chief complaint Brief statement in patient's own words of why patient is in
(CC) topic the hospital or is being seen in consultation
6. Chief complaint Why are you going to see a psychiatrist? What brought
(CC) questions you to the hospital? What seems to be the problem?
7. Chief complaint Record answers verbatim; a bizarré complaint points to
(CC) comments psychotic process.
and helpful hints
8. History of pre- Development of symptoms from time of onset to present;
sent illness relation of life events, conflicts, stressors: drugs; change
(HPI): from previous level of functioning
9. History of pre- When did you first notice something happening to you?
sent illness Were you upset about anything when symptoms began?
(HPI): questions Did they begin suddenly or gradually?
10. History of pre- Record in patient's own words as much as possible.
sent illness Get history of previous hospitalizations and treatment.
(HPI): comments Sudden onset of symptoms may indicate drug-induced
and helpful hints disorder.
11. Previous psychi- Psychiatric disorders; psychosomatic; medical, neurolog-
atric and medical ic illnesses (e.g., craniocerebral trauma, convulsions).
disorders:
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12. Previous psychi- Did you ever lose consciousness? Have a seizure?
atric and med-
ical disorders:
QUESTIONS
13. Previous psychi- Ascertain extent of illness, treatment, medications, out-
atric and medical comes, hospitals, doctors. Determine whether illness
disorders: com- serves some additional purpose (secondary gain).
ments and help-
ful hints
14. substance Substance use disorders can mimic or induce psychiatric
use/abuse syndromes, elevate risk of suicide and violence, and have
important impact on safe medication prescribing.
Various tools can be used to aid in gathering the sub-
stance use history. Examples include the commonly used
CAGE questionnaire which has been modified to include
other drugs (and now called CAGE-AID)
15. Past medical his- The interviewer is interested in obtaining an accounting of
tory major medical disorders both to develop a complete his-
tory and to identify illness that could mimic a psychiatric
disorder, contribute to the context of the presentation or
factor into treatment planning.
16. Family History Psychiatric, medical, and genetic illness in mother, father,
(FH): topic siblings; age of parents and occupations; if deceased,
date and cause; feelings about each family member, fi-
nances .
Because many psychiatric illnesses have a genetic pre-
disposition, if not cause, a careful review of family history
is important to the assessment and can aid in diagnosis
and establishing expected prognosis .
17. Family History Have any members in your family been depressed? Alco-
(FH): question holic? In a mental hospital? In jail? Describe your living
conditions. Did you have your own room?
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18. Family History Genetic loading in anxiety, depression, schizophrenia.
(FH): comments Get medication history of family (medications effective in
and helpful hints family members for similar disorders may be effective in
patient).
19. developmental The developmental and social history reviews the stages
and social of the patient's life from gestation to the present with
history an eye toward understanding the important exposures,
relationships, and events that shaped the person's life
story.
It is often helpful to review the social history chronolog-
ically; doing so provides a natural flow to the questions
and ensures a complete history.
20. Review of sys- As in a general medical interview, the review of systems is
tems intended to capture any current physical signs and symp-
toms not already identified in the HPI or past medical
history (including Table 7.1-2 and is organized by asking
sentinel questions about the major systems of the body).
21. review of sys- Sleep phase problems (initial, middle, terminal insomnia),
tems: sleep total sleep time, abnormal sleep events
22. review of sys- Depression: persistent sadness, reduced interest or plea-
tems: mood de- sure in usual activities, tearfulness, reduced or exces-
pression sive sleep, reduced or increased appetite, weight loss
or gain, low energy, reduced concentration, low libido,
excessive or inappropriate guilt, psychomotor change
(slowing or agitation), negative self-appraisal, helpless
and hopeless thinking thoughts of death or suicide. A
common mnemonic used to remember the symptoms of
major depression is SIGECAPS (Sleep, Interest, Guilt,
Energy, Concentration, Appetite, Psychomotor agitation
or slowing, Suicidality).
23. review of sys- Hypomania/Mania: elevated, expansive or irritable mood,
tems: mood Hy- decreased need for or inability to sleep, excessive energy,
pomania/mania marked increase in goal and pleasure directed activi-
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ty, increase amount and pace of speech and thought,
grandiosity, heightened libido, impulsivity and/or reckless-
ness in behaviors such as spending and sex
24. review of sys- Anxiety
tems: anxiety Experience of panic attacks, somatic symptoms of anxi-
ety, phobic, or social avoidance
25. review of sys- Experience of hallucinations, delusions, disorganized be-
tems: psychosis havior, speech or thought, negative symptoms
26. review of sys- Repetitive intrusive and unwanted thoughts, compulsive
tems: obses- behaviors to neutralize anxiety, hoarding behaviors
sive-compulsive
27. review of sys- Traumatic exposure; intrusive and avoidance symptoms,
tems: trauma negative alterations in cognitions and mood, excessive
arousal and reactivity
28. review of sys- Substance use, gambling, impulse control problems, dis-
tems: behavior ordered eating, repetitive self-harm
29. mental status The MSE is the functional equivalent of the physical ex-
exam amination in other areas of medicine.
It is a systematic collection of the observations (e.g., signs
such as blunt affect or rapid speech) and reported mental
experiences (e.g., symptoms such as depressed mood or
hallucinations) that produce a picture of the patient's cur-
rent mental state. The interviewer makes these observa-
tions throughout an encounter and ultimately documents
the findings together in the MSE section of the evaluation
document.
30. physical exam Psychiatrists do not usually personally conduct compre-
hensive physical examinations but may conduct focused
examinations such as neurological or thyroid examina-
tions. In the outpatient setting, the psychiatrist generally
relies on the PCP to conduct the physical examination
and it is useful in the initial evaluation to record the date of
