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Current Clinical Strategies Psychiatry - Rhoda K Hahn

Current Clinical Strategies Psychiatry - Rhoda K Hahn

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Current Clinical Strategies
Psychiatry
2003-2004 Edition
Rhoda K Hahn, MD
Clinical Professor 
Department of Psychiatry and Human Behavior 
University of California, Irvine, College of Medicine
Lawrence J. Albers, MD
 Assistant Clinical Professor 
Department of Psychiatry and Human Behavior 
University of California, Irvine, College of Medicine
Christopher Reist, MD
Vice Chairman
Department of Psychiatry and Human Behavior 
University of California, Irvine, College of Medicine
Current Clinical Strategies Publishing www.ccspublishing.com/ccs
 
Digital Book and Updates
Purchasers of this book can download the digital book and updates via theInternet at www.ccspublishing.com/ccs.Copyright ©2003-2004 Current Clinical Strategies Publishing. All rightsreserved. This book, or any parts thereof, may not be reproduced, photocopiedor stored in an information retrieval network without the permission of thepublisher. No warranty for errors or omissions exists, expressed or implied.Readers are advised to consult the drug package insert and other referencesbefore using any therapeutic agent. Current Clinical Strategies is a registeredtrademark of Current Clinical Strategies Publishing.Current Clinical Strategies Publishing
27071 Cabot Road
Laguna Hills, California 92653-7011
Phone: 800-331-8227
Internet: www.ccspublishing.com/ccs
E-mail: info@ccspublishing.com
Printed in USA ISBN 1-929622-30-9
 
Clinical Evaluation of the Psychiatric Patient 5
 Assessment and Evaluation
Clinical Evaluation of the Psychiatric Patient
I. Psychiatric HistoryA. Identifying information.
Age, sex, marital status, race, referral source.
B. Chief complaint (CC).
Reason for consultation; the reason is usually adirect quote from the patient.
C. History of present illness (HPI)1.
Current symptoms: date of onset, duration and course of symptoms.
2.
Previous psychiatric symptoms and treatment.
3.
Recent psychosocial stressors: stressful life events that may havecontributed to the patient's current presentation.
4.
Reason the patient is presenting now.
5.
This section provides evidence that supports or rules out relevantdiagnoses. Therefore, documenting the absence of pertinentsymptoms is also important.
6.
Historical evidence in this section should be relevant to the currentpresentation.
D. Past psychiatric history1.
Previous and current psychiatric diagnoses.
2.
History of psychiatric treatment, including outpatient and inpatienttreatment.
3.
History of psychotropic medication use.
4.
History of suicide attempts and potential lethality.
E. Past medical history1.
Current and/or previous medical problems.
2.
Type of treatment, including prescription, over-the-counter medications, home remedies.
F.
Family history.
Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse.
G. Social history1.
Source of income.
2.
Level of education, relationship history (including marriages, sexualorientation, number of children); individuals that currently live withpatient.
3.
Support network.
4.
Current alcohol or illicit drug usage.
5.
Occupational history.
H.
Developmental history.
Family structure during childhood, relationshipswith parental figures and siblings; developmental milestones, peer relationships, school performance.
II.
Mental Status Exam
. The mental status exam is an assessment of thepatient at the present time. Historical information should not be included inthis section.
A. General appearance and behavior 1.
Grooming, level of hygiene, characteristics of clothing.
2.
Unusual physical characteristics or movements.
3. Attitude.
Ability to interact with the interviewer.
4. Psychomotor activity.
Agitation or retardation.

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