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13.04.15 Assessment

Psychiatric history
  • Presenting complaint
  • History of presenting complaint
    • Reason for referral
    • What is the main problem / Which problems are the worst?
    • How has it affected you?
    • Precipitants?
    • When did you last feel well?
  • Past psychiatric history
    • Hospitalisations?
    • Sections?
    • Current treatment / care
  • PMH
  • Medications
  • Social history
    • Accommodation
    • Finances
    • Employment
    • Support
  • Drugs + alcohol
  • Forensic history
  • Family history (incl. psychiatric)
    • Still alive / How did they die?
    • Well?
    • Occupations?
    • Relationship with brothers + sisters
  • Personal history
    • Delivery + early development
    • Schooling
    • Teenage years
    • Relationships with family
    • Psychosexual
    • Employments
  • Premorbid personality
    • Describe themselves before they got ill


Mental state assessment
  • Appearance and behaviour
    • Describe to someone who's never seen them before
      • Don't say "normal"
    • Mannerisms, EPSEs, Posturing, Eye contact, Preentation
  • Speech
    • Form
      • Quantity, Rate, Volume, Rhythm
    • Content (quote if possible)
      • Words, Meanings, Appropriateness
  • Mood and affect
    • Subjective vs Objective
    • Mood (climate) vs Affect (weather)
    • Sleep, Appetite, Libido, Psychomotor, Anxiety, Restlessness, Aggitation, Appropriateness, Congruence
  • Thoughts
    • Form 
      • Abnormal flow
        • Flight, Crowding, Retardation, Circumstantiality
      • Interrupted flow
        • Derailment, Blocking
      • Passivity
        • Withdrawal, Insertion, Broadcasting
    • Content
      • Delusions (Fixed, Unshakeable)
        • Persecution, Grandeur, Religious, Control
      • Judgement
      • Paranoia
      • Ideas + beliefs
      • Reality
  • Perceptions
    • Sensory systems (all)
    • Distortions (Still identified correctly)
    • False perceptions
      • Illusions (Mis-interpreted stimuli)
      • Hallucinations (Absence of stimuli)
      • Pseudohallucinations (Perceive thoughts or memories as voices)
  • Cognition
    • Level of consciousness 
      • Qualitative (vs Quantitative
      • Twilight state, Perseverence, Confabulation, Fugue, Deja vu
  • Insight
    • Not absolute
    • Treatment ideas
    • Cultural factors




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