Introduction: Introduce yourself.

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CC: what’s your understanding of why you’re here?

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Mood: SIGECAPS + DIG FAST

• Sleep: sleeping pattern

• Interest

• Guilt

• Energy

• Concentration

• Appetite

• Psychomotor agitation (observed)

• Suicide: Some people who are going through a tough time have thoughts that life isnt worth living or things would be better if I weren’t around. Have you had any thoughts like that? How often? Plan?

Mania: DIG FAST

• Distractibility, Impulsive (risky behavoir), Grandiosity, Flight of ideas, Activity (time spent), Sleep, Talkativeness

• Less sleep needed

• Decision out of character, more interest in intercourse

• Fast talking and high socialization

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Organic:

•  Any chronic medical conditions

• MAD: Meds, Alcohol, Drugs

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Anxiety: - General Anxiety disorder (ANDICREST): do you worry about different things (Anxiety)? Can you put your worries aside and carry on with your day (not worry)? How long has it been going (duration)? Are you easily irritable (irritability)? Concentration? Restlessness? Energy, Sleep and muscle tension?

Social Anxiety: - do you fear being judged or embarrassed by people?

• Do you avoid being center of attention

• Hate public speaking or social events

Panic disorder: - Had panic attack? How often? How often and whens last time? Symptoms and how long they last for (chest pain, palpitations, sweating, SOB)? Are you worried about dying? Are you in fear of getting the next episode?

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PTSD: - Have you ever experienced physical, mental, or sexual abuse?

• Nightmares?

• Avoid similar places

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OCD: - Do you have frequent thoughts that you find difficult to control?

• Do you have any repetitive behaviors or rituals that take up a lot of your day?

• Do you check things over and over?

• Do they make sense?

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Psychosis: - Have you ever seen things or heard things that other people cannot? What?

• Do you hear voices? Gender? Content?

• Do you think someone is out to get you/conspiracy?

• Radio/TV talking to you

• People can read your thoughts

• Bugs sensation?

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Eating disorder: - Are you satisfied with your weight and body image?

• Diet and meals

• Induced vomiting or laxatives?

• Highest and lowest weight

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Suicide: - Have you had any thoughts that life isnt worth living or things would be better if you werent around? How often?

• People who have had those thoughts often have thoughts like I want to kill myself and this is how I am going to do it. Have you had thoughts like that? Plan, giving away belongings, note?

 

Pmhx/Fmhx/Social/meds: have you seen a psychiatrist before?

 

Mental Status Examination

● Appearance

- Dress, grooming, do they appear their stated age, do they have any

atypical features, height/build, ethnicity, do they look healthy.

Distinguishing features such as scars, birth marks, tattoos

- Clothing, hygiene, objects that patient may have

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● Behavior

- Engagement and rapport, eye contact (reduced, excessive), facial

expression (relaxed, angry), body language, psychomotor activity,

abnormal movements, or postures

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● Speech

- Rate of speech, quantity, tone, volume, fluency, and rhythm

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● Mood and Affect

o Mood is patient’s subjective internal state

o Affect is expressed and an observed emotion

● Thought

o Thought form – organization and processing of thoughts

o Flow of thoughts – loose associations, circumstantial, tangential,

thought blocking

o Thought content – delusions, obsessions, compulsions, suicidal

ideation, homicidal ideations

o Thought possession – insertion, withdrawal, broadcasting

● Perception

o Hallucinations

o Illusions

● Cognition

o Oriented to time, place, and person

o MMSE

● Insight and Judgement