Week 4.1.1: The Clinical Assessment Flashcards
A snapshot of the patient’s current mental state, including their appearance, behavior, mood, thoughts, perceptions, cognition, and insight.
Purpose: Assesses how the patient is doing at the moment of the examination.
Mental State Examination (MSE)
The patient’s personal story, including their difficulties, life context, and how they arrived at the current situation.
Purpose: Provides background information and helps understand the patient’s journey.
Patient’s History
Aggressive or unfriendly behavior.
Hostility
Irrational and persistent feeling of being persecuted.
Paranoia
Perceptions in the absence of external stimuli (e.g., hearing voices).
Hallucinations
False beliefs held despite evidence to the contrary.
Delusions
Information obtained from third-party sources such as clinical notes, family members, general practitioners, or other clinicians.
Confidentiality: Must consider whether access to this information is permissible with or without the patient’s consent.
Purpose: Provides additional context and verifies the patient’s history and current state.
Collateral Information
Physical examination and investigations like blood tests.
Purpose: Ensures there are no physical health issues contributing to the patient’s mental state.
Physical Investigation
How can we identify the patient’s condition based on the gathered information?
Can be diagnosis-based (specific mental health condition) or formulation-based (holistic understanding of the patient’s situation).
The principle of keeping patient information private and only sharing it with consent or when legally required.
Confidentiality
A detailed understanding of the patient’s issues, considering psychological, social, and biological factors.
Formulation
When a patient leaves a hospital or care facility without permission, potentially putting themselves at risk.
Abscond
The main issue or symptom that brought the patient to seek help.
Purpose: Identifies the primary reason for the current visit.
Presenting Complaint
Detailed account of the current issues, including why the patient is seeking help now.
History of Presenting Complaints
Record of previous mental health issues and treatments.
Purpose: Provides context and helps understand patterns and severity of past episodes.
Questions to Ask:
Number of episodes of mental ill health.
Duration of each episode.
Triggers and helpful interventions.
Types of treatment received (e.g., GP, community mental health team, hospital).
Past Psychiatric History
What are factors to consider in the history of presenting complaints of a patient?
Predisposing Factors
Precipitating Factors
Perpetuating Factors
Risks
Conditions or situations that make the patient more susceptible to mental health issues.
Predisposing Factors
Elements that maintain or worsen the mental health condition.
Perpetuating Factors
Events or triggers that lead to the onset of the current issues.
Precipitating Factors
Any immediate risks to self or others.
Risks
Record of previous physical health issues and treatments.
Purpose: Identifies any physical health conditions that might impact mental health.
Past Medical History
Information about mental and physical health issues in the patient’s family.
Purpose: Identifies genetic or familial patterns that might affect the patient’s health.
Family History
Information about the patient’s social, occupational, and personal life.
Purpose: Provides context about the patient’s environment and support systems.
Psychosocial History
The study of mental disorders and abnormal behaviors.
Psychopathology
