History and Examination Flashcards
What is the pneumonic of MSE?
All Sane Men Think That Pizza Is Italian
Appearance & behaviour Speech Mood Thought Form Thought Content Perception Insight IQ (cognition)
Outline what features are assessed in appearance
Distinctive features
- Age, gender, ethnicity etc
Clothing
Posture / gait
Grooming / hygiene
Evidence of self-harm
Outline what features are assessed in behaviour
Eye contact
Facial expression
Psychomotor activity - tremors / ticks / twitches / retardataion
Body language / gestures / mannerisms
Level of arousal - calm / agitated / aggression
Ability to follow requests
Rapport / engagement
Outline what features are assessed in speech
Rate of speech - pressured / slowed
Rhythm and fluency - articulate / clear / slurred
Quantity - minimal / excessive / complete absence
Volume
Tone - monotonous / tremulous
Outline what features are assessed in mood and affect
Mood = sustained state of pt’s inner feelings (weeks - months)
- How are you feeling?
- What is your current mood?
- Have you been feeling low / depressed / anxious lately?
Affect = observable expression of a pt’s inner feelings
- Quality of affect: sad / agitated / hostile, euphoric / animated
- Range of affect: restricted / normal / expansive
- Intensity: normal / blunted / flat
- Fluctuations: labile
Outline what features are assessed in thought form
Speed - accelerated / racing / retarded
Flow / coherence:
Linear - in a logical order
Incoherent - makes no logical sense
Circumstantial - lots of irrelevant / unnecessary details but returns to answer question
Tangential - moves from one thought to the other that relate in some way but never get to the point
Flight of ideas - increased number of ideas, produced at a rapid pace
Perseveration - repetition of a particular response despite absence / removal of stimulus
Outline what features are assessed in thought content
Abnormal beliefs / delusions
Obsessions - pt aware they are irrational but obsessive thoughts continue to enter their head
Overvalued ideas - eg perception of weight in anorexia
Suicidal thoughts
Homocidal / violent thoughts
Thought possession
What questions can be asked to assess thought content?
Whats been on your mind recently?
Are you worried about anything?
Do things seem unreal to you?
Are there any thoughts you have had a hard time getting out of your head?
Do you think anyone is trying to harm you?
Do you have any beliefs that aren’t shared by others you know?
Do you ever think about ending your life?
Have you ever felt that life is not worth living?
Have you ever attempted to end your own life?
Do you ever think about harming people?
What is assessed in thought possession?
Thought insertion
- Do you think people can put ideas in your head?
Thought withdrawal
- Have you ever felt like people have removed / erased things / memories from your mind?
Thought broadcasting
- Do you ever feel like others can hear what you’re thinking?
Outline what features are assessed in perception
Hallucinations
Pseudo-hallucinations
Illusions
Delusions
- Do you ever see, hear, smell, feel or taste things that are not really there?
- Did you think this was real at the time?
- Do you still believe it was real?
Outline what features are assessed in IQ (cognition)
Orientation
- Time
- Place
- Person
Attention and concentration
Short term memory
Detailed testing eg AMTS, MMSE, ACE-III
Outline what features are assessed in insight
Is the pt able to recognise they have a problem or what they are experiencing is abnormal?
What does the pt think is the cause of the problem?
Does the pt want help with their problem?
(+ judgement - eg what would you do if you could smell smoke in your house?)
Outline a psychiatric hx
Presenting Complaint History of presenting complaint Past psychiatric history Past medical history Drugs history Family history Personal history Social history Substance Abuse Forensic history Pre-morbid personality
Outline presenting complaint
Demographics: name, age, marital status, children, employment, housing
In pt own words eg “I’m hearing voices”
Outline history of presenting complaint
Expand on each presenting symptoms
Screen for: depression, anxiety, psychosis, alcohol
Risk: self and others
What is the effect of problems on:
- Relationships, work, social life
- Functioning (work, dressing, cooking)
Treatment: type, compliance, benefit
- Primary care
- Hospital
- Follow up
Outline past psychiatric history
Have you ever experienced anything like this before? Expand
First contact with GP
First contact with psychiatric services
Number of previous admissions
- When, where, duration, symptoms, treatment, follow-up
Ask about DSH, ECT, depts and MHA
Outline PMH
General health / see GP for anything regularly
- DM, asthma etc
- Head injury
- Operations
Outline drug history
Medications
- Name
- Durations
- Dose (adequate trial?)
OTC / self medicated
Aids to compliance
Allergies
Outline family history
Draw family tree
- Parents, siblings, ?extended family
Names, ages, where they live, personality, occupation
Contact and quality of relationship
Health - medical and physical
Outline personal history
1) Birth and childhood
2) Education
3) Employment
4) Relationships
Outline birth and childhood in personal history
Birth - any problems
Upbringing
Happy or not?
Close to who?
Outline education in personal history
Dates of schools attended
Mainstream school?
Enjoy?
Friends / bullied?
Subjects / teachers liked?
Behaviour problems, expelled, truancy
Academic
Aspirations
Outline employment in personal history
For each job:
- Type
- When
- Duration
- Enjoy?
- Why leave
Longest job?
Current job?
- Pay and promotion
Outline relationships in personal history
For each relationship:
- Name
- Age
- Duration
- Good / bad?
- Why end?
- On-going contact
- Children
First partner
List other long term partners (>6mnths)
Longest relationship
Current partner:
- Character traits
- Sexual history
Outline social history
Housing Typical day Relationships ADL Support Occupation Finances Hobbies (+ driving?)
Outline substance misuse
Smoking
Alcohol - CAGE
Illicit drugs:
- What
- How
- Amount
- ££
- Duration
- Impact
Outline forensic history
Any contact with criminal justice system?
Drink-driving
Convictions or sentences
Violence or aggression
Outline pre-morbid personality history
1) Forming and maintaining relationships
- Family / friends / partner
2) Character traits
- Would you say you’re trusting? Suspicious? Caring
3) Predominant mood
- How would you describe your mood most of the time?
4) Reaction to stress
- When you’re under pressure, how do you cope?
5) Hobbies
6) Religion or spirituality
What tools can be used to assess cognition?
Informal used for screening (deficits not diagnosis):
- AMTS
- MMSE
Formal used for diagnosis:
- ACE-III (addenbrooke’s cognitive examination)
What 5 domains are assessed in cognition?
1) Orientation
2) Attention and concentration
3) Memory
4) Language
5) Construction / visuospacial
How is orientation assessed?
Time - day, date, month, year
Place - building, city, country
Person - name, age, DOB, address
How are attention and concentration assessed?
20 - 1 backwards
Count back from 100 in 7s
How is memory assessed?
Antegrade - learning now information and being able to recall it
Retrograde - recall of previously learning information eg monarch, important historical dates
How is language assessed?
Preservation
Confabulation
Word finding problems
How is visuospacial / construction assessed?
Drawing interescting pentagons
Draw a cube
What is a pneumonic for remembering domains of cognition?
Only The Prettiest People Can Actually Make Love Continuously
Orientation Time Place Person Concentration Attention Memory Language Construction
Outline AMTS
1) How old are you
2) What is your DOB
3) What is the year now?
4) What is the time now (nearest hr)
- Ask to remember 24 west street
5) Where are we? What is the building?
6) Who is the current monarch?
7) Date of WW1
8) Count backwards from 20-1
9) Tell me two people in the room / what they do for a living
10) Recall the address given
/ 10
How are scorings classified for ACE-III?
> 88 = normal
83 - 87 = inconclusive
<73 = low
Outline risk assessment
Have you ever thought about hurting yourself in any way?
- If so, how?
- If they ever have then how did they do it, how did they feel when they were doing it?
Have you ever thought about suicide?
Have you ever thought about harming others?
- In psychosis, can ask “have you ever thought about taking measures to protect yourself at all?”
Risk from others:
- Do you feel safe at home / in your relationship?
- Has anyone in your family / partner ever hurt you in any way
What structure is used when performing a psychosocial examination in a child / young person?
HEADSS assessment
1) Home and environment
2) Education and employment
3) Activities
4) Drugs and alcohol
5) Sexuality and relationships
6) Suicide and depression
Outline home and environment in a HEADSS assessment
Who are they living at home with at the moment?
Do they get on well with everyone at home? Who do they get on best with?
Do they feel safe at home?
Do they share a room or a bed with anyone?
Outline education and employment in a HEADSS assessment
Are you in school / college? Which year?
Do you enjoy school? What do you enjoy most / the last? How are you doing at school?
Do you have friends at school? What do you do ay break and lunch time?
What do you want to do when you finish school?
Do you work / have a job? How much?
Outline activities in a HEADSS assessment
What do you do for fun? Where / when?
Do you spend time with friends / family?
Hobbies? TV / reading / sports?
Outline drugs and alcohol in a HEADSS assessment
Have you ever tried alcohol? If so when, with who, how often?
Have you ever tried drugs? If so when, with who, how often?
Does anyone in the house smoke? Lots of teenagers have tried smoking, have you ever tried?
Outline sexuality and relationships in a HEADSS assessment
Are you in a relationship about them?
Can you tell me more about them - age, how did they meet, how old are they?
Lots of young people in relationships develop intimate relationships with their girlfriend/boyfriend, how have you handled this part of the relationship?
Have you ever had sex, with who and when?
What contraception did you use?
Outline suicide and depression in a HEADSS assessment
How is life going in general?
How would you describe yourself? How do you think others would describe you?
Do you ever feel negatively about yourself?
Do you every feel worried about your weight?
Do you ever feel like life isn’t worth living?
Have you ever thought about hurting or killing yourself, have you ever hurt yourself in any way?
Also screen for sleep disorders, appetite/eating changes, abuse
