Psych eval on a patient with Bipolar Disorder

Initial Psychiatric Assessment Template

 

Name of Interviewer: (Your Name)

DATE:

 

Identifying Date:

Name, age, sex, language

 

Chief Complaint:

Reason why patient has come for help, in his/her own words using direct quotations

 

HPI:

Course & chronology of symptoms – onset, symptoms, changes at home or work, setting, problems w/family or friends.  Include Duration, Severity, Contributing Factors, Signs & Symptoms.

 

Over the past 2 weeks regarding HPI:

SIGECAPS (This is a very useful tool for questioning regarding symptomatology in a logical, organized fashion): S=Sleep; I=Interest (anhendonia); G=Guilt; E=Energy; C=Concentration/Focus (increased or decreased); A=Anxiety; P=Psychosis/Psychomotor; S=Suicidal ideations, safety.  Also ask about thoughts to harm others.

Sleep – problems falling or staying asleep, how many hrs/night, naps

Interest – in activities (anhedonia).  What do you do for fun & when was the last time you did this?

Guilt – helpless, hopeless, (worthlessness), crying spells (worry)

Energy – increased or decreased

Concentration – assess later after treatment started

Appetite – increased or decreased, weight loss or gain

Psychomotor – observe for retardation or agitation

Suicidal ideation – SI/HI

Psychosis: any AH/VH

Mania: decreased need for sleep?  Racing thoughts, pressured speech, flight of ideas, hypersexuality, overspending, gambling?

Anxiety:  Describe how it feels in your body?

Safety:  Do you feel safe in your environment?

 

Past Psych History:

Past episodes requiring psych care (inpatient, outpatient, presenting symptoms, extent of incapacity, type of treatment, any medications utilized in the past and response, names of doctors & hospitals involved

PMH:

PSH:

Allergies:

Current Medications: Including prescribed and OTC

 

Substance Abuse:

Currently or in the past – ETOH, nicotine, marijuana, Spice, huffing, opiates, amphetamines, meth, cocaine, BZO’s (CAGE = Cutting down, Annoyed, Guilty, Eye Opener).  Including any past history of rehab/treatment programs.

 

Family Medical History:

Other family members with psychiatric/mental problems including Bipolar Disorder, Anxiety, Depression, Schizophrenia, Substance abuse, hospitalizations & any psych meds utilized

 

Family History of Mental Illness:

 

Social History:

Marital status, children, relationship w/patient, living situation, education, occupation, income, encounters with the law/legal problems.  Get good background information including the following: Where were you born, who raised you, what was your childhood like, any past history of trauma (physical, emotional, sexual), highest level of education.

 

Legal:  Any history of legal problems, arrests, etc.

 

HABITS:  Ask about caffeine intake including coffee, sodas, energy drinks.

 

History of Trauma:  Any history of Emotional, Physical or Sexual abuse as a child or adult

 

Perform a General ROS and then a Psychiatric ROS:

General:

HEENT:

Resp:

Cardio:

GI:

GU:

NEURO:

ENDOCRINE:

HEME:

SKIN:

Consciousness:

Reduced, clouded, narrowed, expanded

 

 

 

 

 

 

 

MENTAL STATUS EXAM

Orientation:

Time, place, situation, self

Attention, Memory:

Apperception, concentration – (100 – 7 = 93 – 7 = 85 – 7 = 78 – 7 = 71 – 7 = 64 …..), memorization (apple, table, cello), retention, confabulations, paramnesias; impaired memorization and ocular motor function; consider Wernicke’s encephalopathy!

Formal Thought Disorders:

Thinking – inhibited, retarded, circumstantial, restricted;

Formal order – preservation, rumination, pressured thinking, flight of ideas, tangential thinking, blocking, incoherence;

Perception and abstract thinking – explain proverbs, neologisms

 

 

Phobias & Compulsions:

Suspiciousness, hypochondriasis (non-delusional), phobias, obsessive thoughts, compulsive impulses, compulsive actions

 

Delusions:

Ask specific questions.  Often in schizophrenia – delusional references, delusions of persecution; often in affective psychosis – delusions of guilt or of poverty; hypochondriacal delusions; often in manic – DO or schizophrenia – delusions of grandeur; further delusions – delusional ideas, systemic delusions, delusional dynamics, delusional jealousy, other delusions

 

Perception:

Illusions; hallucinations – verbal auditory, visual, bodily, olfactory

 

Loss of Ego Boundaries:

Derealization, depersonalization, thought broadcasting, withdrawal, thought insertion, other symptoms

 

Disturbances of Affect:

Depressive DO:   perplexity, loss of feeling, blunted affect, depressed mood, hopelessness, anxiety, inadequacy, feelings of guilt, feelings of impoverishment

Manic DO: euphoria, dysphoria, irritability, exaggerated self-esteem

Schizophrenia: ambivalence, parathymia

Organic DO: affective lability/incontinence

Others:  loss of vitality, restlessness, complaintive, affective rigidity

 

Psychomotor Disturbances:

Volition:  lack of drive, inhibited, increased

motor activity: motor restlessness, parakinesia, mannerisms, histrionic

speech: mutism, logorrhea,

catatonic symptoms: negativism, stupor, waxy flexibility

Introspection,  Judgement & Insight, Suicidal thoughts (ask specific questions)

 

INVENTORY OF PATIENT’S ASSETS/STRENGTHS: (Indicate those present)

General Fund of Knowledge Average or Above Average; Intelligence; Active Sense of Humor; Supportive Family / Friends

Physical Health; Motivation for Treatment/ Growth; Capable of Independent Living; Ability for Insight

Communication Skills; Financial Means; Religious Affiliation; Hobbies / Interests

Work/Volunteer Skills; Other: List Below

 

INVENTORY OF PATIENT’S LIABILITIES: (Indicate those present)

Unresponsive; Uncooperative; Lack of Support System; Unmotivated

Financial Difficulties; Legal Difficulties; Marital Difficulties; Lack of Coping Skills

Poor Judgment; Limited Insight; Limited Cognitive Abilities; Other: List Below

 

Diagnosis: (Include most likely diagnosis along with differential diagnoses as well as corresponding ICD-10 codes)

 

 

Treatment Plan: (Include thorough treatment plan including recommendations for medication management, therapy, labs/other diagnostic studies, medication side effects and health promotion/prevention strategies)

 

 

 

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