Psych/Mental Health Assessment Flashcards
Presenting problem in the patient’s words.
Chief complaint
COLDSPA - characteristics of symptoms, onset, lingering frequency of symptoms, duration symptoms last, stressors, precipitating triggers, alleviating factors.
History of present illness/problems (HPI)
Previous inpatient/outpatient care, diagnoses, providers, medications used and effectiveness.
Past psych history
Relationships, education, occupation/finances, living arrangements, trauma, legal involvement, hobbies.
Social history
Mother’s pregnancy, developmental milestones, speech/occupational/physical therapy, learning disabilities/special accommodations.
Developmental history
Family pedigree - medical and psychological, family diagnoses including substance use, known and suspected genetic predispositions.
Family history
Strengths, competence, areas of improvement - self-identified and observed.
Personal evaluation
Religious/spiritual beliefs, source of strength/comfort/hope, supports.
Culture and spiritual evaluation
Previous medical problems including surgeries and hospitalizations, chronic disease, comorbidities, current diagnoses and medications/effectiveness, history of head trauma and significant infections, allergies including foods, and subjective report of systems.
Medical history
Sleep frequency, duration, evaluation of restfulness; nightmares, waking, daytime naps. Changes with age - more late night wakefulness and need for longer sleep in late childhood and adolescents and more early night tiredness and early morning/frequent awakening in elder years.
Sleep patterns/evaluation
Inhibits brainstem arousal nuclei which leads to inhibition of wake center and produces restful sleep.
Ventrolateral preoptic nucleus (VLPN) in hypothalamus
Rapid eye movements, EEG activation, muscle atonia, muscle twitches, breathing irregularities, declines with organic brain dysfunction.
REM sleep
CAGE assessment for alcohol use
Need to Cutback, people Annoyed by it, feelings of Guilt, need for Eye-opener.
Alcohol use, illicit drug use, cannabis use, prescription med use, caffeine intake, tobacco, vaping, OTC med use, other substances/pica.
Substance use evaluation
Objective documentation of observed presentation of patient NOT subjective patient reporting. General appearance, eye contact, motor activity; mood; affect; memory; attention and orientation; speech; thought content; thought process; insight and judgement; intellect (appropriate to age and developmental level).
Mental Status Exam
Vital signs, neurologic exam, brief physical assessment
Review of systems
Clock drawing with correct time listed and observation of patient independently completing task. Different scoring mechanisms depending on assessment used.
Brief cognitive exam
ORAL 23 RWD - orientation to place and time, recognition of 3 objects, attention (serial 7s counting backward from 100), recall of previous 3 objects, language, identification of 2 objects from picture, following 3-step command (take paper in right hand, fold it in half, place it on floor), reading statement to self and performing direction (“close your eyes”), writing a sentence, drawing a design.
Mini-mental state exam (MMSE)
Scoring: maximum of 30; no cognitive impairment 24-30; delirium/dementia 18-23 (mild), 0-17 (severe).
MMSE
11 items measuring cognition through orientation, short-term memory, calculations, naming of animals, clock drawing, and recognition of geometric figures. Scores of 27-30 normal in individual with high school education, 21-26 indicate mild cognitive impairment, and scores 0-20 indicate dementia. Advantage of no cost (in public domain) and earlier detection of deficit.
SLUMS (St. Louis University Mental Status exam)
Social support presence, Lethal plan, Access to means, Plan and/or previous attempts.
SLAP assessment for suicidal risk
Ideation, Substance use, Purpose for living lost, Anxiety, Trapped feeling, Hopelessness, Withdrawing from loved ones, Anger/rage, Reckless behavior, Dramatic mood change.
IS PATH WARM assessment for suicide risk
Either depressed mood (irritability in children/adolescents) most of day nearly every day x2 weeks and markedly diminished interest in activities. Additional symptoms include SIGECAPS - Sleep disturbance, Interest deficit (anhedonia), Guilt, Energy deficit, Concentration deficit, Appetite change, Psychomotor agitation or retardation, Suicidality.
DSM-V diagnosis for depression
9-item self-report questionnaire. Scoring: 1-4 = minimal symptoms, 5-9 = mild symptoms, 10-14 = moderate, 15-19 = moderately severe, 20-27 = severe.
PHQ-9 (Patient Health Questionnaire) for depression
