PSC 168 Lecture Notes - Lecture 3: Psychiatric History, Mental Status Examination, Substance Abuse
Document Summary
Reasons for referral and assessment (including chief complaint - what is the reason you made an appointment for) History of current problem (including precipitants, stressors, symptoms, duration of symptoms, etc) Client social history (current living situation/ marital/ employment/ financial circumstances) Family history (including history of abuse- physical, sexual; family psychiatric history) All current medications (including dosage, effectiveness; side effects) All past medications (including dosage, effectiveness, side effects) Assess for each substance and when substance was last used (alcohol, coffee, cocaine, marijuana, prescription drugs, etc. ) See next page for a complete mental status exam outline (do it after you see the client- good reminder for appearance and conversation) Content (clear, flight of ideas; rhyming, neologisms, circumstantial, etc. ) Content (ideas of reference, obsessions, phobias, fantasies, grandiosity) Knowledge of illness (symptoms, medications, side effects) Sleep (increase, decrease, nightmares, early morning awakening, frequent awakening, trouble going to sleep) Ideation? (in present/ in past/ current plan?)
