Psychiatry Junior Clerkship
The Psychiatric Interview and  Mental Status
Examination

The following format is generally accepted, with mild alterations made per individual attending.

I. Identifying Information

Start the write-up/presentation with a clear statement about the patient which helps the listener/reader get a picture of the person. Example: 54 yo married white female who is 8 months pregnant.

II. Chief Complaint

This is the patient's chief complaint, and you should write down what the patient states is the reason for coming in to be evaluated. Do not use technical terminology unless the patient does - rather, put down exactly what the patient says usually in quotations. Example: Patient's chief complaint is: "I feel depressed;" patient's chief complaint is: "I need a refill of medicine."

III. History of Present Illness

Write down an organized, chronological history of what brings the patient into the hospital now, including all significant symptomatology, precipitating factors, etc... If the patient is presenting to you with a six month history of depression which started when the patient's father died, start six months ago with the death of the father and report what has been going on since then, in chronological order, up until the current time of the interview. Include significant modifiers of the illness, including possible organic factors, drug, and alcohol abuse.  List all pertinent positive and negative symptoms, which will help you to make an accurate DSM-IV (differential) diagnosis.

IV. Past Psychiatric History

Put in all contact the patient has had with therapists (psychiatrists, psychologists, social workers, and counselors), inpatient units, and other outpatient experiences. Be sure to include prior rehabilitation programs.  If the patient has been on psychotropic medications in the past, list these by date, how long the patient took each one, at what dose, and the effect the medication had on the patient. List any ECT the patient might have had. Also list prior suicide attempts and methods.

V. Past Medical History

List in this area any current medical problems the patient has, and then any past medical, surgical or obstetric problems the patient has had, in chronological order. List the hospitalizations. List all medications (including doses) the patient is currently taking. List any allergies the patient has and what the specific reactions to the medications were.

VI. Family History

A genogram is often useful here for clarity. List all illnesses that patient's family has had, including medical, psychiatric, and substance abuse history. Write down any psychotropic medications which have been beneficial in family members.  Include suicide attempts or completed suicide in family members.  Include whether the family members are currently living or are dead. Include patient's parents, siblings, and children.

VII. Social History/Developmental History

List all substances the patient currently is taking; drugs, alcohol, cigarettes. List how much the patient uses of each, how often, for how many years and in what form (smoke, IV, etc...). Document when the last time used.  List patient's educational history, work history, and what the patient currently does to support himself/herself. Are there any ongoing legal issues, felonies, warrants, etc... Ask who the patient currently lives with. Ask about the patient's marital status, sexual orientation, sexual activity, children, etc...

VIII. Review of systems

Put in this category any other information you might have received; i.e., the patient told you he is short of breath a lot,  he has blurred vision. It is sometimes useful to ask a patient to tell you anything he considers important for you as the physician to know that you have not yet asked.

IX. Mental Status Exam

The mental status exam is extremely important. The best mental status exams allow the person listening to the presentation to develop a snapshot of the patient being presented. 

Appearance: Start out the mental status exam by giving a verbal picture of the patient, what the patient is doing, wearing, and how the patient looks. For example: 16 yo BM wearing age appropriate dress of clean jeans, a t-shirt, and sneakers with the laces undone. He was sitting on the floor playing with a train set. He looked up and smiled when the interviewer approached.

16 yo BM O X 3 is a lot less descriptive!

After the initial description you have probably already taken care of the general appearance, alertness, hygiene and grooming part of the general description, but if not, include some information here. Look for use of grooming that might be suggestive of a mood state or disorganization. Don't use diagnostic labels, just describe what you see.

Speech: volume, rate, idiosyncratic symbols or other odd speech, tone (include any accent or stuttering).

Motor activity: rate (agitated, retarded), purposefulness, adventitious (non-voluntary).

Mood: ask how they are feeling, usually put in quotes: "depressed," "sad," "great," etc...

Affect: observable emotion (euthymic, neutral, euphoric, dysphoric, flat), the range (full, constricted, blunted), whether  it fits appropriate to stated mood or content, lability.

Thought process: organization of a person's thoughts (logical/linear, circumstantial, tangential, flight of ideas, loose associations or thought blocking).

Thought content: basic themes preoccupying the patient, sucidality, homicidality, paranoia, delusions, ideas of reference, obsessions, compulsions.  If there is suicidal or homicidal ideation, is there a plan, intent?

Perceptual disturbances: hallucinations (auditory, visual, olfactory, tactile), illusions,
de-realization/depersonalization.

Cognitive: level of alertness and orientation.  May want to perform full Folstein MMSE if concerned about dementia or delirium.

Insight: into level of illness and/or need for treatment/hospitalization.

Judgment/Impulse control: best determined by history of patterns of behavior and current attitude.

IX. Physical Exam

Many medical diseases masquerade as psychiatric, and vice versa (pancreatic CA, hypothyroidism, brain metastases). Do a thorough PE including full neurological exam and document. This usually does not  include a breast, pelvic, rectal, or genital exam on inpatients.

X. Problem List

XI. Differential Diagnosis

XII. Plan

Include biological (medications, labs, studies), psychological (individual therapy, group therapy, psychological testing), and social (housing, access to care, social services), interventions.

MULTI AXIAL ASSESSMENT