PSYCHIATRY CLERKSHIP
Psychiatry can be a very educational experience as one wanders into the realm of affective, personality, mental and substance abuse disorders. Many students have found that to be successful in the rotation one must be able to conduct clear, concise goal oriented interviews and have a highly descriptive vocabulary to match the pathology you see. The forms below, such as the "Psychiatric Evaluation and "Daily Soap Note" will assist you to organize your interviews. The "Descriptive Terms" is basically a vocabulary sheet which is helpful in choosing just the right word to describe the emotions, activities and feelings of your patients.
Psychiatric Evaluation
Crisis Evaluation
Daily Soap Note
Mini Mental Status Exam
Global Assessment of Functioning
Descriptive Terms
PSYCHIATRIC EVALUATION
IDENTIFICATION
- Name, age, birth date, marital status, number of children, ethnic status, religion, occupation, education , social class, handicaps,
etc.
- Identification of informants (if not patient). Mood and apparent biases and reliability of informants.
CHIEF COMPLAINT
- Verbatim statement from patient.
PRESENTING ILLNESS
- Chronological order of symptoms and treatments.
- Life changes, stressors or conflicts.
- Past psychiatric diagnosis (severity of illness, treatments, drug abuse).
PERSONAL HISTORY
- Birth and Early Development - pregnancy, complications, psychophysiological
- Childhood - personality traits, behavior problems, social/family relationships, school adjustment
- Adolescence -
- Marriage - age, times, current relationship, children
- Education - highest attained, academic success, behavior/social
- Occupational History - current job, previous job, relationships, aspirations
- Sexual History - feelings, performance, desire, deviant behavior, fantasy
- Social History - interpersonal relationships, group activities, follower/leader, premorbid personality
- Current social situation - living arrangements, income, social environment, risk behavior, stability
FAMILY HISTORY
- Who lives at home, relationships, role in family, etc.
- Psychiatric history of family and relatives
MEDICAL/SURGICAL HISTORY
MENTAL STATUS EXAM
- Appearance - overall impression, posture, clothes, grooming, health, apparent age, angry/afraid
- General Behavior - mannerisms, gestures, combative, rigid, twitching, psychomotor retardation
- Attitude toward examiner - cooperative, hostile, defensive, seductive, evasive, ingratiating
- State of consciousness - lethargic, alert, hyper alert
- Attention - concentration, attend, digit recall
- Orientation - person, place, time, situation
- Psychomotor Activty - increased, reduced, agitated, abnormal movements
- Mood - overall emotional state (sad, happy, depressed, elated, anxious, irritable)
- Affect - current emotional state (full, labile, restricted, flat, inappropriate, suicidal/homocidal,
- Speech - rate (incr, pressured, slow), tone (soft, angry) volume, articulation, language (aphasia)
- Form of thought - circumstantial, flight ideas, evasiveness, loosening associations, perseverence, blocking
- Content of thought - preoccupations, obessessions, phobias, rituals, delusions, depersonalization
- Perceptions - misperceptions, illusions, hallucinations,
- Judgement -
- Memory - immediate (digit span), recent (three objects at 5 minutes), remote (days to years)
- Insight - do they realize they are ill
- Intellectual Functioning- fund of knowledge, calculations, abstraction (proverbs, similarities)
CRISIS INTERVENTION
IDENTIFICATION INFORMATION
- Name, age, birth date, marital status, number of children, ethnic status, religion, occupation, education , social class, handicaps,
etc.
- Identification of informants (if not patient). Mood and apparent biases and reliability of informants.
REFERRAL SOURCE
- How did the patient get referred to crisis intervention
PRESENTING PROBLEM
MENTAL STATUS EXAM
- Appearance - overall impression, posture, clothes, grooming, health, apparent age, angry/afraid
- General Behavior - mannerisms, gestures, combative, rigid, twitching, psychomotor retardation
- Attitude toward examiner - cooperative, hostile, defensive, seductive, evasive, ingratiating
- State of consciousness - lethargic, alert, hyper alert
- Attention - concentration, attend, digit recall
- Orientation - person, place, time, situation
- Psychomotor Activty - increased, reduced, agitated, abnormal movements
- Mood - overall emotional state (sad, happy, depressed, elated, anxious, irritable)
- Affect - current emotional state (full, labile, restricted, flat, inappropriate, suicidal/homocidal,
- Speech - rate (incr, pressured, slow), tone (soft, angry) volume, articulation, language (aphasia)
- Form of thought - circumstantial, flight ideas, evasiveness, loosening associations, perseverence, blocking
- Content of thought - preoccupations, obessessions, phobias, rituals, delusions, depersonalization
- Perceptions - misperceptions, illusions, hallucinations,
- Judgement -
- Memory - immediate (digit span), recent (three objects at 5 minutes), remote (days to years)
- Insight - do they realize they are ill
- Intellectual Functioning- fund of knowledge, calculations, abstraction (proverbs, similarities)
SUBSTANCE ABUSE
FAMILY HISTORY
- Who lives at home, relationships, role in family, etc.
- Psychiatric history of family and relatives
PRIOR TREATMENT HISTORY
COLLATERAL INFORMATION FROM FAMILY, MD INTERVIEW
DIAGNOSTIC IMPRESSION
- Axis I
- Axis II
- Axis III
- Axis IV
- Axis V
PLAN
DAILY SOAPNOTE
S:
- How feeling, sleep, eating, meds, etc
O:
- Appearance
- State of consciousness
- Affect
- Mood
- Attitude
- Speech
- FOT
- COT
- Audio/Visual Hallucinations
- Insight
- Judgement
A:
- Thought process
- Contact with reality
- Behavior
- Mood
- Nourishment
- Ability to care for self
- Compliance
P:
Descriptive Terms
| VERBAL HOSTILITY | PHYSICAL HOSTILITY | HOSTILE ATTITUDE
| | venomus | murderous | malicious
|
| abusive | assaultive | embittered
|
| threatening | destructive | surly
|
| derisive | combative | provocative
|
| derogatory | hot blooded | resentful
|
| scronful | even tempered | irritable
|
| argumentative | peaceable | petulant
|
| critical | harmless | grudging
|
| nagging | inhibited | civil
|
| outspoken | placated | agreeable
|
| frank | cringing | gentle
|
| tactful |
| concillatory
|
| softspoken |
| gracious
|
| complimentary |
| ingratiating
|
| flattering |
| fawning
|
| SEXUAL ATTITUDE | PHYSICAL SEXUALITY | GUILT
| | Lewd | Assaultive | self-condeming
|
| Lustful | Wanton | self-reproachful
|
| Erotic | Over-active | remorseful
|
| Sensual | Soliciting | ashamed
|
| Romantic | Passioniate | chagrined
|
| Unsure | Assertive | regretful
|
| Prim | Amorous | concerned
|
| Prudish | Permissive | indifferent
|
| Ashamed | hesitant | unfeeling
|
| Puritanical | passive | unreformed
|
| Disgusted | restrained | cynical
|
| inhibited | unrepetent
|
| apthetic | hardened
|
| abstinence | shameless
|
| MOOD | ANXIETY | IDEATION
| | euphoric | terrified | Delusional
|
| elated | panicky | ruminative
|
| frivolous | agitated | day-dreaming
|
| bouyant | tremulous | fanciful
|
| gay | apprehensive | musing
|
| jovial | tense | contemplative
|
| light-hearted | fretful | thoughtful
|
| cheerful | uneasy | matter-of-fact
|
| placid | composed | literal
|
| sober | calm | unreflective
|
| serious | non-chalant | unimaginative
|
| solemn | unconcerned | stolid
|
| grave | cool | vacuus
|
| gloomy | bland |
|
| brooding | stoic |
|
| disconsolate |
|
|
| hopeless |
|
|
| SELF ESTEEM | EMOTIONAL WARMTH | SOCIABILITY
| | self-exalting | over-indulgent | intrusive
|
| pompous | doting | meddlesome
|
| conceited | affectionate | gregarious
|
| boastful | sentimental | comradrie
|
| vain | tender | companionable
|
| cocky | sympathetic | aggreeable
|
| confident | kindly | accessible
|
| self-respecting | considerate | hesitant
|
| modest | cool | reserved
|
| unassuming | unresponsive | bashful
|
| humble | detached | reticent
|
| self-doubting | unfeeling | shrinking
|
| self-effacing | hardened | seclusive
|
| forlorn | rejecting | withdrawn
|
| self-debasing | frigid | solitary
|
| IMPULSIVENESS | AMBITION | FLEXIBILITY
| | incontinent | grandiose | spineless
|
| reckless | pretentious | over-suggestible
|
| rash | aspiring | yielding
|
| impetuous | enterprising | docile
|
| excitable | persistent | changeable
|
| hasty | eager | amendable
|
| abrupt | content | adaptable
|
| restless | self satisfied | conventional
|
| spontaneous | complacent | persistent
|
| self-possessed | lackadaisial | habit-bound
|
| cool-headed | indifferent | stubborn
|
| controlled | listless | perservering
|
| restrained | indolent | unbending
|
| staid | apathetic | mulish
|
| sluggish | lethargic | intractable
|
Global Assesment Function and Mini Mental Status Forms Coming Soon!