University:
Western Sydney University
Course:
MEDI 2003 | Clinical Sciences 2
Academic year:

2024
Views:

452

Pages:

3
Author:

Mariam A.

Psychiatric assessment         Identifying data. o Name, age, gender. o Referral reason. o Recent events. Presenting complaint. o Reason for visit. o Events/stressors. o Ask about symptoms and complaints (neuro-vegetative symptoms: sleep, energy, appetite, interest, libido). o Current treatment, medications or allergies. Past history. o General medical or surgical. o Psychiatric. o Risk behaviours. o Addictions. Family history. o Medical, psychiatric, drugs and alcohol. o Relationships. Development history. o Birth milestones, early neuroses. o Schooling. o Relationships. o Significant events (e.g. trauma or abuse). Personality. o View on themselves, and what they perceive others to view them as. o Self-esteem. o Cultural, spiritual beliefs and values. o Interests and hobbies. Mental state examination. o Appearance and behaviour. o Speech and thought form. o Thought content. o Mood (observed and reported). o Perception. o Cognition. Physical examination. o Vital signs and weight. o General medical. o Neurological. o Effects from alcohol and other drug use. Formulation and diagnosis  Why has this patient presented with these symptoms/problems at this time  Consider biological, psychological and social factors.  Level of current risk to self and others.  Diagnostic, aetiologic and prognostic statement. Multiaxial diagnostic scheme  Primary psychiatric diagnosis.  Psycho-social stressors.  Global assessment of function. DSM  Descriptive, not aetiologic.  Not hierarchical but some diagnoses will ‘trump’ ohers (e.g. anorexia nervosa vs. bulimia nervosa).  Rigorous and reproducible criteria.  Validated with: o Descriptors of associated features. o Prevalence and incidence. o Risk. o Course. o Complications. o Predisposing factors. o Familial pattern. o Differential diagnosis. Depressive disorders  Episodic vs. dysthymia.  Reported biological features (e.g. sleep, appetite, libido).  Observed biological features (e.g. slowing and agitation).  Change in self and future-view. Diagnostic statement  A list of alternatives in order of their probability.  For each diagnosis factors for and against a diagnosis are stated.  At the end of the list, the most probable diagnosis is stated as a conclusion. Aetiological statement  Considering predisposing factors, precipitating factors and maintaining factors.  The reasons for any predisposition are then considered, usually in chronological order to show how each factor built on those that went before.  Protective factors may also be noted.  Further data that would clarify the differential diagnosis and aetiological understanding. Prognostic statement  Make a firm prediction.