Psych H&P Template

Identifying info: Name: age: Housing status: gender: M / F / O occupational status: E / UE / D marital status: M / P / S / D socio-economic status: Low / Medium / High Informant: Who is the informant – name and relationship to patient? ✓ Reliability (Is the information consistent, corroborative, and continuous?) Y / N ✓ Adequacy (Is the information adequate to come to a provisional diagnosis?) Y / N Presenting complaints: (main 3-4 complaints preferably in patients words avoid technical terms and arrange in chronological order) First: ✓ Onset: (The time period between when symptoms started and reached maximum intensity. Abrupt (within 48 hours) Acute (within 2weeks) Insidious (gradual) ✓ Course: Continuous Fluctuating Episodic ✓Progression: ✓ Precipitating factor: (Record significant events – biological or psychosocial which may be deemed to be associated as a triggering factor with the onset of illness). Second: ✓ Onset: Abrupt (within 48 hours) Acute (within 2weeks) ✓ Course: Fluctuating Continuous ✓Progression: ✓ Precipitating factor: Insidious (gradual) Episodic Third: ✓ Onset: Abrupt (within 48 hours) Acute (within 2weeks) ✓ Course: Continuous Fluctuating Insidious (gradual) Episodic ✓Progression: ✓ Precipitating factor: Fourth: ✓ Onset: Abrupt (within 48 hours) Acute (within 2weeks) Insidious (gradual) ✓ Course: Continuous Fluctuating Episodic ✓Progression: ✓ Precipitating factor: History of presenting illness: Elaborate the presenting complaints in a descriptive manner to elicit all information pertaining to the symptoms. The flow of description should be such that at the end of history the listener should be able to make a fair estimation of possible diagnosis. One way is to think of differential diagnosis for your complaints and arrange your information including and excluding possible diagnosis. In psychiatric history it is easy to get carried away by describing only contextual factors and stressors reported by over anxious informants. While they are important they do not help in diagnosis and decision making. It may be necessary for interviewer to filter information and focus on eliciting symptoms. Thumb rules to follow: ✓ Elaborate each presenting complaints for onset, duration, progression, ✓ Ask for and cover symptoms in all 3 domains of thought/emotions/behavior ✓ Describe the Socio-occupational dysfunction caused by the symptoms ✓ A good way to do this is to describe a typical day of the patient and activities over a 24 hour period ✓ Describe Biological functions – Sleep/appetite/sexual activity ✓ Describe associated stressors ✓ Check for history of substance use ✓ Always check for risk of harm to self or others (Suicidal ideation/attempts/aggression) ✓ Check for potential legal issues Start negative history with: ▪ Symptoms of likely diagnosis which are not present in this patient ▪ Other psychiatric symptoms which are absent to rule out differential diagnosis ▪ Neurological and Medical symptoms/conditions that may be associated with the likely diagnosis Treatment history: (Details of past treatment – Drug given. Duration of treatment, compliance, and adverse effects if any, and if there was any response) Past psych history: (Details of past illness. Typically in episodic illness, only current episode is described in HOPI and details of past episodes come here) Family history: Record following information ✓ 3 generation genogram ✓ Family history of medical or psychiatric disorder (Psychosis, bipolar disorder, depression, suicide, substance use, dementia). The diagnosis may not be clear, describe the symptoms and behavioral disturbances, and record their treatment history if available (for e.g. family history of response to lithium may predict good response to lithium in this patient also). Social history; ✓ Record current living arrangement and who is primary care giver ✓ Record family understanding of illness and attitude towards the patient also record any family stressors, interpersonal difficulties Personal history: ✓ Antenatal history and birth complications ✓ Developmental milestones ✓ Childhood history for enuresis, nail biting, school refusal, truancy, conduct symptoms, ADHD, temper tantrums ✓ Schooling history: record average academic performance, last class studied, grades/marks in 10th and 12th standard and reasons for drop out ✓ Occupational history: Jobs held, performance, reason for loss of job. Ask specifically for any frequent job changes, impersistence in work etc. ✓ Marital history: Record for duration of Married life, nature of marital and sexual relations, marital discord if any, details of family of procreation. ✓ Sexual history: Check for sexual misconceptions, high risk sexual behavior ✓ Menstrual history in female patients Premorbid personality: Ask about the individual’s attitude to work/family, ability to take responsibility, coping when faced with stress, hobbies and interests prior to onset of illness. In young adults/adolescents temperamental history needs to be taken. General appearance and behavior: Give a good observational description. ✓ General appearance and grooming ✓ Rapport – could be established/very easily established and overfamiliar/difficult to establish – guarded/hostile ✓ Eye to eye contact – maintained/fleeting/hyper vigilance/avoids/downcast ✓ Any observed repetitive motor movements – tics/mannerisms/stereotypies/motor perseveration/catatonic signs Psychomotor activity: ✓ Increase in goal directed activity/retardation ✓ Agitation ✓ Hand gestures while conversation ✓ Hyperactivity Speech: ✓ Tone (loudness) of speech – normal/increased/decreased ✓ Tempo (rate or speed) of talking – normal/increased/pressure of speech/decreased ✓ Volume (amount) of speech. Estimate words per minute – verbose/pressure of speech/decreased ✓ Prosody – emotional intonations of speech ✓ Reaction time – increased/decreased Thought: Form: Obtain speech sample on a neutral topic. Assess for poverty of thought/poverty of thought content/circumstantiality/flight of ideas/tangentiality/loosening of associations and derailment/neologisms Stream: Observe for flow and continuity of thought process – Flight of ideas / prolixity / retardation / perseveration / thought block Possession: Disorders of thought related to the ownership of thought ✓ Thought broadcast – thought diffusion/thinking in unison /audible thoughts ✓ Thought insertion ✓ Thought withdrawal ✓ Obsessions – describe if thoughts are repetitive/intrusive/irrational/ego dystonic/person’s own thoughts. Also mention the form (ideas/impulses/images/doubts/ruminations) and content of obsessions ✓ Compulsions – motor/cognitive Content: ✓ Delusions – Give verbatim description given by patient and then give your impression whether belief is - Fixed/firm/false/not in keeping with socio-cultural background/morbid origin. Describe content of belief (persecutory/ referential/ misinterpretation/grandiose/ hypochondriacal/ etc). If there are multiple delusions also describe whether they are - Single/multiple elaborate/non-elaborate bizarre/nonbizarre systematized/non-systematized ✓ Overvalued ideas ✓ Depressive cognitions – hopelessness/worthlessness/helplessness ✓ Death wishes or suicidal ideation – Describe frequency, intensity of ideas and whether there are any active plans ✓ Preoccupations & ruminations – somatic/anxious/depressive Mood: ✓ Subjective mood: Ask – “How has been your mood for most periods of the day over the last one week” – give verbatim description given by patient. ✓ Affect: Cross sectional observation of facial emotional expression, motor behavior, gestures, posture, speech (Euphoric/irritable/depressed/anxious/perplexed/restricted/blunted or flat). ✓ Range: intact/restricted ✓ Reactivity: preserved/absent ✓ Lability: (rapid shifts of mood during interview) present/absent ✓ Appropriateness to situation and congruency to though process Perception: Give verbatim description of quality and content of perception given by patient and then give your impression whether the phenomenon: Occurs in clear consciousness/ clear and vivid/ objective or subjective space / patient has insight into it / control on the experience And give your impression whether the perceptual abnormality is a hallucination/pseudo hallucination/imagery and which modality it occurs in. Other phenomenon: Describe phenomenon such as somatic passivity/ depersonalization/ derealization here. Insight: ✓ Awareness: That experiences are out of the ordinary/not real or normal/deviant ✓ Attribution: To psychological/somatic causation for the experiences ✓ Acceptance: Of treatment for the same Also grade insight from 1-6. ✓ Complete denial of illness ✓ Slight awareness of being sick and needing help, but denying it at the same time ✓ Awareness of being sick but blaming it on others, on external factors, or on organic factors ✓ Awareness that illness is caused by something unknown in the patient ✓ Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences ✓ True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior. Cognitive function assessment: Consciousness: Alert / drowsy but arousable with minimal stimulus / obtunded arousable with deep stimulus / stuporous Orientation: ✓ Time – Ask approximately what time of the day it is now without looking at the time (Approximation should be within ± 2 hours). ✓ Place – Ask patient to identify his surroundings and which place he is in ✓ Person – Ask whether patient can identify himself and then people around him Note: Patient should be alert and well oriented to proceed for the remainder of cognitive function assessment. Attention: ✓ Digit span test: Give serial digits sequences and ask patient to repeat them after you have presented the sequence. Numbers should be read clearly and rate of 1 number per second. First complete the forward sequence then present the backward sequence. Normal range of digit forward is 7 +/- 2 (5 to 9) and digit backwards is 5 +/-2 (3 to 7). Forwards Backwards 7-4-9 1-7-4 8-5-2-7 5-2-9-7 2-9-6-8-3 6-3-8-5-1 3-8-1-5-9-2 5-2-9-1-7-4 ✓ Serial subtraction test: Ask patient to perform 100 minus 7 in 2 minutes, 40 minus 3 in 1 minute and 20 minus 1 in 20 seconds. More than 2 mistakes is taken as abnormal. Illiterate subjects can be asked to name days of week backwards (They should be able to tell the backward sequence correctly for 5 steps starting from Friday). Language: ✓ Spontaneous speech & Fluency (animal naming test – number of animals patient can name in 1 minute). ✓ Comprehension: verbal commands/pointing questions/multistep commands ✓ Naming: naming common objects such as pen, coin ✓ Reading and writing Note: If attention and language is impaired the interpretation of the rest of the tests of cognitive assessment is doubtful. Memory: ✓ Immediate memory: Digit span test / Serial subtraction test as above or 3 word registration. Instruct patient that you will be giving 3 words which they should listen carefully, repeat them after you have said them and try to remember them as you will be asking them to recall it later. The three words should be unrelated and not present in the room – eg: Lotus, cat, blue ✓ Recall: Ask patient to recall words after 5 minutes. Note if they require a cue to recall / confabulation. Alternative address test may be used. Give an address with 5 points to remember and assess recall after 5 minutes. For eg: # 215, 9th Cross, 2 Main, Vijay Nagar, Bangalore ✓ Remote: Ask if person can recollect Personal information like marriage, child birth, schooling, occupation and Semantic information like year of independence or events of national importance General information: ✓ General fund of information: common knowledge such name of local rivers, important towns in your area, important personalities. This question is very subjective and needs to be asked based on education and socio-cultural background of the patient Calculation: ✓ Calculation: Assess for simple calculation abilities, both verbal and written – addition, subtraction, multiplication, division. Arithmetic problem solving questions (for eg: if you go to a shop and buy chocolates. Each chocolate costs 50 paise. How may chocolates can you buy for 4 rupees. I f you have 20 rupees with you and and a banana cost Rs 7. How much money will you have left?) Abstraction: Describe whether the responses are abstract/semi abstract/ concrete ✓ Test for differences between pairs of objects (stone and potato, chair and table) ✓ Test for similarities between pairs of objects (orange and apple, bird and aeroplane) ✓ Ask to tell a proverb in his own language and the real meaning of the proverb. If patient cannot recall, give him some proverbs in his own language and ask for meaning. Judgment: ✓ Test: Give specific responses and ask what would the patient do in these scenarios (What would you do if you saw that your neighbor’s house is on fire? What would you do if you saw that a child was crawling towards an open well?) ✓ Personal: Ask what is the patients immediate future plan after discharge from the hospital ✓ Social: Impression of judgment is made based upon history of behavior over last one week and cross sectional observation. Intelligence: Make an estimate of overall intelligence level based on comprehension, general information, calculation, abstraction and judgment. Specific lobe function test: ✓ Luria motor sequence: Fist palm side test- Ask the subject to hit the top of the desk repeatedly, first with a fist, then with the side of the hand, then with an open palm with his/her right hand. Demonstrate the task thrice with your left hand, make the subject do it with you thrice and then allow the subject to perform it on his own at least 6 times. Look for errors of missing the sequence or perseverative errors. ✓ Visual pattern completion test: Ask the patient to copy the below figure and continue the pattern ✓ Go no go test: Given the instruction to patient “tap once when I tap once and do not tap when I tap twice.” Give a practice and then tap in the sequence - 1-1-2-1-2-2-2-1-1-2. Look for errors of omission/commission/perseveration. ✓ Visuo-spatial construction: Ask patient to copy figures presented below. Ensure visual acuity before interpreting. ▪ Cross ▪ Cube ▪ Intersecting pentagons ▪ Clock drawing - “Please draw a picture of a clock with the numbers and set the hands at 2:30” ✓ Apraxia: Listen to my instructions carefully and perform the action I ask you to do imagining that you are holding that object in your hand ▪ Show me how to open a lock with a key ▪ Show me how to comb your hair ▪ Show me how to open a toothpaste, put the paste on your toothbrush and brush your teeth. Note: While presenting; cognitive functions should be reported prior to ‘thought’ as interpretation of MSE findings is dependent on intact cognitive functions, though while performing MSE we may have assessed it in the end. Patient name Date MEDICAL/PSYCHIATRIC HISTORY (Patient Self Report) CURRENT PROBLEMS Current problems Duration (months) Additional information: CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present) None = This symptom not present at this time Mild = Impacts quality of life, but no significant impairment of day-to-day functioning Moderate = Significant impact on quality of life and/or day-to-day functioning Severe = Profound impact on quality of life and/or day-to-day functioning depressed mood [None] [Mild] [Mod] [Sev] appetite disturbance [None] [Mild] [Mod] [Sev] euphoric mood [None] [Mild] [Mod] [Sev] hallucinations [ ] [ ] [ ] [ ] mood swings [ ] [ ] [ ] [ ] paranoid ideation [ ] [ ] [ ] [ ] sleep disturbance [ ] [ ] [ ] [ ] irritability [ ] [ ] [ ] [ ] delusions [ ] [ ] [ ] [ ] social isolation [ ] [ ] [ ] [ ] hyperactivity [ ] [ ] [ ] [ ] bingeing/purging [ ] [ ] [ ] [ ] fatigue/low energy [ ] [ ] [ ] [ ] racing thoughts [ ] [ ] [ ] [ ] anorexia [ ] [ ] [ ] [ ] psychomotor retardation [ ] [ ] [ ] [ ] poor concentrations [ ] [ ] [ ] [ ] self-mutilation [ ] [ ] [ ] [ ] lack of interest [ ] [ ] [ ] [ ] aggressive behaviors [ ] [ ] [ ] [ ] significant weight gain/loss [ ] [ ] [ ] [ ] poor grooming [ ] [ ] [ ] [ ] oppositional behavior [ ] [ ] [ ] [ ] laxative/diuretic abuse [ ] [ ] [ ] [ ] guilt [ ] [ ] [ ] [ ] panic attacks [ ] [ ] [ ] [ ] substance abuse [ ] [ ] [ ] [ ] hopelessness [ ] [ ] [ ] [ ] anxiety [ ] [ ] [ ] [ ] other [ ] [ ] [ ] [ ] grief [ ] [ ] [ ] [ ] phobias [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] sexual dysfunction [ ] [ ] [ ] [ ] obsessions/compulsions [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] worthlessness [ ] [ ] [ ] [ ] nightmares [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] EMOTIONAL/PSYCHIATRIC HISTORY [ ] [ ] Prior outpatient psychotherapy or counseling? No Yes If yes, on occasions. Longest treatment by for sessions from / to / Provider Name Month/Year Month/Year Prior provider name City Diagnosis Intervention/Modality Beneficial? [ ] [ ] Prior hospitalization for a psychiatric or addiction problem? No Yes If yes, on occasions. Most recentt treatment at from / to / Name of facility Month/Year Month/Year Your prior psychiatric diagnoses: [ ] [ ] Has any family member been treated for psychiatric, emotional, or substance use disorder? No Yes Family Member Diagnosis Type of treatment (medication name, counseling) _____________ ____________ _________________________________________________________ _____________ ____________ _________________________________________________________ _____________ ____________ _________________________________________________________ Your current psychiatric medications Medication Name Dosage Frequency Start date Side effects Beneficial? Your past psychiatric medication usage Medication Name Dosage Frequency Start date End date Side effects Beneficial? Previous suicide attempts or self injurious behaviors (describe type; date; severity):____________________ ______________________________________________________________________________ ______ ______________________________________________________________________________ ______ FAMILY HISTORY Present during childhood: Parents' current status: Describe childhood family experience: Present Present Not [ ] married to each other [ ] outstanding home environment entire part of present [ ] separated for years [ ] normal home environment childhood childhood at all [ ] divorced for years [ ] chaotic home environment mother [ ] [ ] [ ] [ ] mother remarried times [ ] physical/verbal/sexual abuse witness father [ ] [ ] [ ] [ ] father remarried times [ ] physical/verbal/sexual abuse victem stepmother [ ] [ ] [ ] [ ] mother deceased stepfather [ ] [ ] [ ] [ ] father deceased brother(s) [ ] [ ] [ ] sister(s) [ ] [ ] [ ] Age at time of leaving home: Circumstances: Special circumstances or abuse suffered in childhood: CURRENT FAMILY Marital status: Relationship satisfaction: List all persons currently living in your household: [ ] single, never married [ ] very satisfied with relationship Name Age Sex Relationship to patient [ ] engaged [ ] satisfied with relationship [ ] married for years [ ] dissatisfied with relationship [ ] divorced for years [ ] ___ prior marriages (self) [ ] not currently in relationship List children not living in your household: Describe any past or current significant issues in intimate relationships: Describe any past or current significant issues in other immediate family relationships: MEDICAL HISTORY Your current medical problems: Is there a history of any of the following in the family: _________________________________________________________ [ ] tuberculosis [ ] heart disease [ ] birth defects [ ] high blood pressure _________________________________________________________ [ ] emotional problems [ ] alcoholism [ ] behavior problems [ ] drug abuse List any known allergies: [ ] thyroid problems [ ] diabetes [ ] cancer [ ] Alzheimer's disease/dementia [ ] mental retardation [ ] stroke List any medications currently being taken (give dosage & reason): [ ] other chronic or serious health problems Describe any serious medical hospitalization or accidents: Date Age Reason Past Surgeries: ___________________________________________ Date Age Reason DEVELOPMENTAL HISTORY Problems during Birth: Childhood health: mother's pregnancy: [ ] normal delivery [ ] chickenpox (age ) [ ] lead poising (age ) [ ] cesarean delivery [ ] ear infections [ ] mumps (age ) [ ] none [ ] complications [ ] whooping cough (age ) [ ] diphtheria (age ) [ ] high blood pressure [ ] rheumatic fever (age ) [ ] polios (age ) [ ] drug use [ ] pneumonia (age [ ] asthma [ ] German measles Infancy: [ ] scarlet fever (age ) [ ] tuberculosis (age ) [ ] emotional stress [ ] toilet training problems [ ] significant injuries [ ] cigarette use [ ] sleep problems [ ] alcohol use [ ] feeding problems [ ] allergies to Delayed developmental milestones (check only Childhood/adolescent emotional and behavior problems: those milestones that did not occur at expected age): [ ] drug use [ ] disobedient [ ] distrustful [ ] sitting [ ] controlling bowels [ ] alcohol abuse [ ] not trustworthy [ ] extreme worrier [ ] speaking words [ ] controlling bladder [ ] chronic lying [ ] hostile/angry mood [ ] frequently daydreams [ ] playing cooperatively [ ] dressing self [ ] stealing [ ] hyperactive [ ] impulsive [ ] walking [ ] riding bicycle [ ] violent temper [ ] immature [ ] easily distracted [ ] feeding self [ ] tolerating separation [ ] fire-setting [ ] assaults others [ ] poor concentration [ ] breaks things [ ] animal cruelty [ ] often sad/tearful Social interaction: Intellectual / academic functioning: [ ] normal social interaction [ ] inappropriate sex play [ ] normal intelligence [ ] authority conflicts [ ] mild retardation [ ] isolates self [ ] dominates others [ ] high intelligence [ ] attention problems [ ] moderate retardation [ ] very shy [ ] associates with acting-out peers [ ] learning problems [ ] underachieving [ ] severe retardation [ ] alienates self [ ] other Current or highest education level Degrees/GED: Describe any other developmental problems or issues: SUBSTANCE USE HISTORY Family alcohol/drug abuse history: Personal substances used/abused: Current Use (complete all that apply) First use age Last use age (Yes/No) Frequency Amount [ ] father [ ] stepparent/live-in [ ] alcohol [ ] mother [ ] uncle(s)/aunt(s) [ ] amphetamines/speed [ ] grandparent(s) [ ] spouse/significant other [ ] Cannabis/MJ/THC [ ] sibling(s) [ ] children [ ] heroin/opiates/pain meds [ ] other [ ] cocaine [ ] crack cocaine [ ] nicotine/cigarettes [ ] inhalants (e.g., glue, gas) [ ] other Personal treatment history: Consequences of substance abuse (check all that apply): [ ] outpatient (age[s] ) [ ] hangovers [ ] withdrawal symptoms [ ] sleep disturbance [ ] binges [ ] inpatient (age[s] ) [ ] seizures [ ] medical conditions [ ] assaults [ ] job loss [ ] 12-step program (age[s] ) [ ] blackouts [ ] tolerance changes [ ] suicidal impulse [ ] arrests [ ] stopped on own (age[s] ) [ ] overdose [ ] loss of control amount used [ ] relationship conflicts [ ] other (age[s] [ ] other SOCIO-ECONOMIC HISTORY Current living situation: Social support system: Sexual history: [ ] housing adequate [ ] supportive network [ ] heterosexual orientation [ ] currently sexually dissatisfied [ ] homeless [ ] few friends [ ] homosexual orientation [ ] age first sex experience [ ] housing overcrowded [ ] distant from family of origin [ ] bisexual orientation [ ] age first pregnancy/fatherhood [ ] dependent on others for housing [ ] no friends Additional information: Employment: Military history: Cultural/spiritual history: [ ] disabled: [ ] never in military ethnicity (e.g., Hispanic, Caucasian): [ ] employed and satisfied [ ] served in military religious identity: __________________________________________ [ ] employed but dissatisfied currently active in community/recreational activities? Yes [ ] No [ ] [ ] unemployed currently engage in hobbies? Yes [ ] No [ ] [ ] supervisor conflicts currently participate in spiritual activities? Yes [ ] No [ ] [ ] coworker conflicts if answered "yes" to any of above, describe: Legal history: Financial situation: [ ] no legal problems [ ] relationship conflicts over finances [ ] court ordered this treatment [ ] now on parole/probation [ ] impulsive spending [ ] arrest(s) not substance-related [ ] poverty or below-poverty income [ ] arrest(s) substance-related [ ] no current financial problems [ ] jail/prison time(s) [ ] large indebtedness total time served: Template: Mrs. ____ is a _____ year old woman with (relevant PMH, PSH) who presented to the ED/her PCP with (chief complaint: put it in the patient’s words/layman’s terms) for ____ hours/days/weeks. Template: So in summary, this is a ___ year old ____ who presented with ____. (summarize current state and current interventions). On Assessment, the patient’s presentation is most consistent with a diagnosis of __________, but _______ and _______ are also possible. It The most likely diagnosis is _______ given that _________, __________, and _________. It is also possible that the diagnosis is _____________ or ___________ given ___________, but these are less likely given _________.