Psychiatry history taking, mental status examination, case formulation and management template

Name : (Initials of patient’s name)

Age :
Sex :
Marital status:
Residence:
Race:
Occupation:
Religion:
Mode of admission: (voluntary/involuntary/emergency)
Date of admission:

Allegations:

Reactions to allegations:
(Accepts or rejects the above allegations; helps to gain insight on patient’s condition)

History of presenting illness:

(Explore the allegations and qualify them in terms of onset, duration, precipitating and mitigating
factors; Also note the patient’s attribution to the symptoms i.e., why they believe they are having these
symptoms. Inquire about impact of illness on patient’s life i.e., education, relationship with friends,
occupation etc. Explore on patient’s coping mechanisms both good and bad. Neuro-vegetative
symptoms include: sleep, energy, concentration, hobbies, appetite and libido)
Risk history:

History of active or passive suicide or homicidal ideation; (if positive complete a suicide risk assessment
asking about frequency, method, lethality, patient’s expectations on death, future intention)

History of self-neglect;

History of substance use: (Debut, frequency, effects of substance of social-occupational function, screen
of alcohol use disorder if present)

Past psychiatric history: (Passed admissions, presentations, facility type, length of stay, effects of
treatment, compliance to medication)

Past medical history:

Drug history: (Both herbal & pharmaceutical drugs + adherence to medication; inquire if on follow-up in
any mental health institution)

Family History: (Immediate family members, relations with siblings in terms of number, age, occupation,
medical/mental status, marital status, interpersonal relations with siblings, family deaths and causes,
residence, extended family tree)

Social history: (Inquire about socio-economic status; Job description including income per month,
working conditions i.e., working hours, stress at work, Accessibility to health care, urbanity, Teenage
parenthood, Relationships: marital status, previous relationships, relations with religious groups,
Immigration history, Exposure to domestic violence; dangerous neighborhood, crime)

Personal history:
Early childhood: (Behavioral problems, earliest memories, temperament as a child)
Education: (Schooling including level of education and grades attained, role in school, discipline i.e.,
suspensions & expulsions, peer relations)

Profession and career:

Marriage: (Including previous marriage if divorced or separated)

Forensic history:
Arrests:

Charges:
Premorbid history: (Personality, how do they view self/others/world; core beliefs; self-esteem; coping
skills)

Systemic review:

Vitals:

HR:
BP:
RR:
Temp:

General examination:

Icteric/ anicteric sclerae

Conjunctival/ palmar pallor

Central/ peripheral cyanosis

Finger clubbing

Lymphadenopathy

Edema

Oral thrush

Dehydration

Mental status exam.

1. General appearance and behavior
(a) Appearance
Estimated age: 20s/30s/40s/50s etc…; (doesn’t) appears his age.
Body habitus: endomorph/mesomorph/ectomorph/obese/underweight/marfanoid

Posture: seated/lying; upright/slouching; open/closed; tensed/relaxed;

Hygiene: Clothes: unkempt/kempt; hospital uniform/no hospital uniform; distinguishing features

Body odor: yes/no

Halitosis: yes/no

Dress: appropriate/inappropriate (seductive, excessive make-up, flamboyant clothing)

(b) Behavior
Eye contact: maintains/doesn’t maintain; fleeting/ intrusive

Rapport: easily established/not easily established; maintained/not maintained

Attitude: friendly/hostile/evasive/co-operative/secretive/apathetic/focused/easily distracted

Level of distress: no distress/ distress because of pain/psychomotor agitation/glancing repeatedly at

different parts of room/

(c) Abnormal motor activity

Disinhibition/mannerisms/tics/stereotypy/restless/abulia/apraxia

2. Mood and Affect

(a) Affect; Quality: dysphoric/neutral/euphopric/euthymic/detached/anxious/irritable/sad/angry,elated

Congruence: congruent/incongruent for mood.

 Range: broad/restricted; flat/blunted; full/exaggerated; labile/fixed

(b) Mood: sad/happy/guilty/exhausted/frustrated/frightened/indifferent/marvelous/embarrassed

3. Speech
Rate: rapid/normal/slow/pressured/poverty of speech

Volume: loud/normal/soft/ whispered

Articulation:
incomprehensible/accented/shuttered/lisping/mumbled/slurred/clear/fluent/neologisms/echolalia/dys
arthia/mutism

4. Thought evaluation
(a) Process: circumstantiality/tangentially/loose associations/flight of ideas/clang
associations/perseveration/thought blocking

(b) Content: specific delusions/phobias/suicidal or homicidal ideation/ obsessions and pre-occupations

5. Sensorium and cognition

(a) Orientation: disoriented (confused)/oriented in time, place and person

(b) Level of consciousness: alert/drowsy/lethargic/obtunded/stupor/comatose/delirious

(c) Attention and concentration: intact/impaired; serial 5 or 7 subtraction from 100

(d) Memory; Immediate: intact/impaired. (retrograde/anterograde/global amnesia)

Short term: intact/impaired (retrograde/anterograde/global amnesia)

Long term: intact/impaired.(retrograde/anterograde/global amnesia) confabulation

(e) Fund of knowledge: adequate/inadequate for level of education.

(f) Abstract thinking: proverb/similarities testing; Intact/impaired;

6. Perceptual disturbances
specific hallucinations/illusions/dissociations/agnosia/hemi-neglect

7. Insight and judgement

(a) Insight: Grade1,2,3 or 4/anosognosia.

(b) Judgement: Test judgement/personal judgement intact/ impaired

Case formulation

Primer: (Brief summary including biodata, important positives and negatives form history and
examination findings)

Biological Psychological Social

Predisposing  Genetic vulnerabiliy
(Vulnerabilities)  Toxin exposure in utero
 Birth complications
 Traumatic brain injury
 Neuro-developmental
disorders
 Sex of patient (M/F)
Medical & Family History
 Attachment style
 Personality style
 Isolation
 Insecurities
 Fears/Phobias
 Low self-esteem
 Rigid or negative
cognitive style
Family & Social History
 Domestic violence
 Poverty & adversity
 Teenage parenthood
 Poor access to health
care
 Divorce
 Immigration or
Marginalization or
Discrimination
 Childhood exposure to
maternal depression
 Childhood exposure to
domestic violence
 Late adoption
 Temperament mismatch
Social History
Precipitating  Serious medical illness or
(Stressors) injury
 Increasing use of alcohol or
drugs
 Medication non-adherence
 Pregnancy or hormonal
changes
 Sleep deprivation
Medication and Substance History
Presenting illness & Social History
Perpetuating  Chronic illness, functional
(Maintaining) impairment caused by
deficits
 Lack of medication
optimization i.e., sub-
therapeutic dosages
 Lack of treatment follow-
up for mental illness
 Current substance use
 Chronic medical problem;
chronic pain
 How is the patient
responding to
hospitalization?
 What degree of symptoms
is currently present?
Medical, Medication & Substance
History
Protective  Good overall health
(Strengths)  Absence of family
psychiatric history
 Good response to
medication
 Above average intelligence
 Easy temperament
 No substance use history
 Balanced diet, adequate
sleep, physical exercise
Medical, Medication & Substance
History
Stressors that can activate;
 Cognitive: core beliefs &
distortions
 Dialectical: emotional
dysregulation and
dysfunction
 Interpersonal: grief,
loss, disagreement, role
transitions
 Psychodynamic:
unconscious conflicts &
defense mechanisms
 Re-experiencing
abandonment
 Beliefs about self or
others or world
 Self-destructing coping
mechanism or traumatic
re-enactments
 On-going poor coping
skills
 Lack of insight
 Unable to maintain
consistent interpersonal
relationships
MSE, Presenting illness & Social
History
 Able to see another
person perspective
(metallization)
 Positive sense of self or
adaptive coping
mechanisms
 Good coping skills
 Good insight
 Reflective & capacity to
change thinking pattern
MSE, Presenting illness, Social
History
 Loss or separation from
close family, partner or
friend
 Interpersonal trauma
 Work or academic or
financial stressor
 Recent immigration
 Loss of home
 Loss of supportive
service e.g., appropriate
school placement
 Cyberbullying on social
media
Social History
 Chronic marital or
relationship discord
 Lack of empathy from
family or friends
(stigmatization)
 Chronic dangerous or
hostile neighborhood
 On-going transitions and
stressors
 Poor finances
 Long working hours
 Social isolation
Social History
 Supportive relationships
 Good interpersonal
relationships
 Religious or spiritual
beliefs
 Financial stability
 Has access to outpatient
health care (GP,
Psychiatrist or social
worker)
Social History
Working diagnosis

Diagnosis: (Include specifier if possible)

Justification: (supporting evidence from case formulation)

Differential diagnosis

1.

2.

3.

4.

Management plan

1. Investigations

(a) Biologic
Physical exam:

Lab:

Imaging:

(b) Psychological
(c) Social

2. Treatment

(a) Biologic (Pharmacotherapy or physical therapy)

(b) Psychosocial

(I) Family based interventions:

(II) Social skills training

(III) Cognitive behavioral therapy:

Prognosis

Good prognostic factors include:

Poor prognostic factors include: