History and Examination Flashcards
MSE: Insight
- Does the patient understand they are unwell? This is not an all or nothing phenomena.
- Do they understand the purpose of treatment?
MSE: Cognition
- Does the patient understand they are unwell? This is not an all or nothing phenomena.
- Do they understand the purpose of treatment?
MSE: Perception
- Hallucinations – which can be in lots of different modalities e.g. auditory, visual etc
- Pseudohallucinations
MSE: thought
- THOUGHT “FORM” e.g. does the patient appear to be talking logically in response to questions asked? How is it structured.
- THOUGHT “CONTENT” e.g. what is the patient thinking about? Do they have any worries or
cognitions linked to anxiety? Are they depressed and thinking about themselves in a very
negative way? Do they have any delusional beliefs? - SUICIDAL IDEATION – you could consider asking about risk in the Thoughts section. Just
make sure it is covered for each patient. You can introduce this in several ways. For example
when talking to a depressed patient – “… sometimes when people feel very depressed, they
feel that life isn’t worth living, do you think that?” “… sometimes people also feel that life
isn’t worth living and they have thoughts about harming themselves or ending their life …
MSE: Affect and mood
Mood is usually described subjectively by the patient,
and then objectively by the
interviewer
Affect - emotional response
MSE: Speech
- Rate (e.g. manic patients often talk extremely quickly: pressure of speech)
- Rhythm
- Tone
- Volume
- Dysarthia
- Dysphasia
MSE: Appearance and behaviour
- Description of the individual, their physique, state of dress (appropriate, flamboyant, formal), well kempt of unkempt, etc.
- Psychomotor activity e.g. agitated or retarded, significant slowing of speech or pacing around the room
- Tics
- Rapport - easy vs forsted or gaurded
- EPMS - parkinsonian gait, pill rolling tremor
- Any abnormal behaviours
- Eye contacts
What are the seven aspects of a mental state examination?
- Appearance and Behaviour
- Speech
- Affect / Mood
- Thought
- Perception
- Cognition
- Insight
What is the basic structure of a psychiatric history?
P/C, HPC
PAST PSYCH HISTORY **
PMH
DHX
SOCIAL HX
DRUG AND ALCOHOL ** - more in depth
PERSONAL HISTORY
PREMORBID PERSONALITY **
How do people present to psychiatric services?
Self present to GP or A&E if they have insight
Police referral for bizarre behaviour or serious crime
Friends or family - memory loss, talking to themselves, changes in behaviour
Possible presenting complaints in psychiatry?
Low mood
Anxiety
Paranoia
Self harm/suicide attempt
Weight loss
Elated mood
Personality change
Memory loss/decline in functioning
Hearing/seeing things
Physical symptoms
Poor sleep
Aggression
Irritability
How to explore presenting complaints
Onset+ precipitants
Severity
Duration
Aggravating and relieving factors
Associated symptoms
Clarification of terms patient uses - depression
Presenting complaint: Overdose
Had you thought about it before? (planned)
What was taken and how much?
What did they think would happen?
Any preparations in the event you were successful? (final acts)
How did you come to the attention of the medical services - i.e. were they found or did they seek help?
How do they feel about it now?
P/C: Negative delusional beliefs
Clarify:
That sounds frightening, how do you know it’s happening? How can you be sure? When did you first notice it? Could there be any other explanation? What do other people say about that? Is there any chance you could be mistaken?
Risks: What steps are they taking to ‘‘protect themselves’’
Past psychiatric history
Have they ever had treatment for a mental illness before, if so:
- By who? GP or Psychiatrist
- If seen by psychiatrist - community and/or inpatient
- If admissions - informal or MHA, number, length
- Previous risk - any previous harm to self or others - if so, ask about the occasion led to the most serious harm to you
What is significant about current medications in psychiatry patients?
Compliance - lower in psych, especially if no insight
Side effects - can be serious - hyperlipidaemia, weight gain, impaired glucose tolerance
Social Hx
What type of property lived in?
Owned, rented coincided
Who do they live with - any children
Any benefits
Any POC
Drugs+Alchohol
Smoking - how many
Drinking - what, how much, how often
Illicit drug use - what, when, how often
History of dependence?
Personal history
Pregnancy and birth abnormalities - infection, prematurity, problems in labour
Early childhood development - milestones: walking, talking, etc
Childhood - How do they look back on their childhood, prolonged separation from parents, how did they get on with their family
Education - age of leaving, academic achievement, friends/bullying
Employment - rough chronological history - of job type and length, of time in each job, reasons for leaving
Relationships - sexuality, current and previous significant relationships, children
Forensic history - any charges/convictions, sentences
Abuse - at some point when appropriate should ask specifically about any type of abuse - emotional, neglect, physical, sexual?
Premorbid personality
A description by them/their family of their personality before they were unwell
Their predominant mood/emotions e.g. a worrier or happy go luck, a perfectionist vs laid back
Might also want to consider religious beliefs/attitudes
Objective description of mood:
Depressed
Anxious
Manic
Irritable
Euthymic (normal)
What is affect?
Emotional responiveness
How to describe affect?
Blunted - decrease in variation of emotional expression
Flat - virtually complete absecnce of affective expression
Inappropriate/incongruous - emotions are expressed are not congruent with the content of patient’s thoughts
Labile - rapid and sometimes extreme changes in emotional state. Seen in mania
Reactive - i.e. normal/appropriately responsive/reactive
Thought content vs form
Form - refers to wherther or not the thoughts are ordered coherently and logically - if not, described as ‘formal thought disorder’
Content - Refers to the predominant themes preoccupying the patient and their nature (important diagnostically). Might include:
Delusions
Overvalued ideas
Obsessions
Phobia
Most common Formal thought disorders
LOOSENING OF ASSOCIATIONS - the loss of the normal structure of thinking. Loss of connection between thoughts. Change topic between thoughts. Worst extreme is word salad.
FLIGHT OF IDEAS - Thoughts (& therefore speech) move quickly from one topic to another - so that one train of thought is not carried on to the point of completion. There is usually a link that is identifiable for the change in topics e.g. distracting cue in the environment or distraction from a word used (may pun on a words of rhyme)
What types of delusions are suggestive of which conditions?
Schizophrenia
Persecution, reference, control, thought possession
Mania
Grandeur
Psychotic depression
Poverty, guilt, nihilism
Thought content: overvalued ideas
An understandable/comprehensible idea that preoccupies a patient and is pursued by them beyond usual expectations
Cognition assessment
Time place and person usually sufficient unless any of the above impaired or ?dementia or ?delerium
Risk
- to self (self harm, suicide, self neglect)
- to health (worsening mental illness, deteriorating physical health)
- to others (paranoid delusions, command hallucinations)
