While the HPI is generally the same across the board, every specialty will have it’s own particular spin on it depending on what it is. Psychiatry is no different.
Why is the patient at the doctor’s office or hospital. Asking the patient this can give you some insight into their thought process and perception. However, sometimes it will be necessary to ask the patient’s family, friends, or whomever brought them there (EMS, police, etc). Include any pertinent information about the current episode (what led up to it, what happened), any previous episodes, how is this affecting the patient’s life, assess the patient’s support system, symptoms, and evaluate patient’s functioning.
Ex: 45 year old gentleman brought to ER by police, was found wandering in street at midnight yelling incoherently. The patient states he is here because his family is trying to kill him and take his fortune. This is the patient’s fifth visit at this hospital in the last two years, and is well known to the treatment team. In the ER the patient was visibly responding to internal stimuli.
- Past psychiatric history
Have they ever been diagnosed with a psychiatric illness, and if so, when? If there were any prior suicide attempts, include when they occurred and the methods used.
Ex: Patient was diagnosed with paranoid schizophrenia 25 years ago. He denies suicidal or homicidal ideations.
- Past medical history
The usual drill.
Ex: HTN, DMII
Many psych patients are on medications, be sure to ask if they miss doses and how often. Include supplements.
Ex: risperidone, metformin, lisinopril. Patient has not picked up prescriptions in 2 months per pharmacy, patient states he does not need medicines.
The usual drill.
- Family history
Specifically interested in family psychiatric history, don’t forget to ask about suicides.
Ex: Per medical record, patient’s mother had bipolar disorder and his father committed suicide when the patient was 7.
- Social history
Ask about what a patient does for a living, how far they went in school, where they live, who else is in the home with them, how their childhood was, specifically ask about physical, sexual, verbal, and emotional abuse in their lifetime, ask about specific drugs (marijuana, coke, heroin, meth, etc), tobacco use and history, and alcohol use and history.
Ex: patient is homeless and is on disability, he reports snorting heroin in the last two months, he smokes a pack of cigarettes a day (started smoking at age 13) and drinks a fifth of whiskey when he can get it. After his father’s suicide he was sexually abused by his mother’s boyfriend until he was placed into foster care at 12. His only family contact is a sister, who states she has not seen or heard from the patient since February.
- Review of systems
Still important to ask, but can be basic. I ask about dizziness, headache, runny nose, sort throat, cough, chest pain, heart racing, nausea, vomiting, abdominal pain, diarrhea, constipation, trouble urinating, and muscle or joint pains.
- Physical exam
Most psych patients are very healthy and will have exams within normal limits. IT IS VERY IMPORTANT TO STILL EXAMINE THEM LIKE YOU DO ANY OTHER PATIENT.
- Mental status exam
This is the most important part other than the history. Also remember this is just a snapshot of the patient’s mental status at the time of questions, it can- and frequently does- change during the course of the patient’s treatment.
+ Appearance: physical (hygiene, posture), behavior (cooperative/noncooperative, eye contact good/fair/poor), attitude (guarded, hostile)
Ex: Patient appears disheveled and malodorous, poor eye contact, guarded but cooperative)
+ Speech: rate (pressured/fast/regular/slow), volume (loud/average/soft), tone (angry/sad)
Ex: Speech is slow, soft, and lacking intonation. He answers questions mostly in monosyllables.
+ Mood: what does the patient say about how they are feeling?
Ex: Patient states he is afraid.
+ Affect: How does the patient’s mood appear to you? Is it congruent with what the patient says (the patient says they are the saddest they’ve ever been but they are smiling and laughing)? Assess quality (flat/none, blunted/shallow, constricted/limited, full/average, and intense/greater than average) and motility (how fast they shift emotional states, sluggish/supple/labile).
Ex: Patient’s affect is flat with sluggish motility
+ Thought process: How the patient thinks and puts ideas together. Examples of descriptions can be loosing of associations (no logical connections), flight of ideas (fast stream, tangents), thought blocking (lack of communication, unable to get thoughts out), tangentiality (goes off on tangents without returning to questions), and circumstantiality (goes off on tangent but returns to question eventually).
Ex: Patient demonstrated thought blocking.
+ Thought content: How the patient expresses their ideas. Examples of description can be poverty/overabundance of thought, delusions (fixed false beliefs not shared by patient’s culture), suicidal and homicidal ideations, phobias (irrational fears), obsessions (intrusive recurring thoughts), and compulsions (repetitive behaviors, often linked to obsessions).
Ex: Patient demonstrates poverty of thought with paranoid delusions.
+ Consciousness: alert, drowsy, stuporous
+ Orientation: person, place, and time
+ Calculation: add/subtract simple equation (2+4, 10-5)
+ Memory: Assess immediate (can they remember 3 repeated words after 5 minutes), recent (what happened in the last week), recent past (what happened last few months), remote past (events from years and years ago)
+ Fund of knowledge: Who is the President/leader of country? Be sure to stay within bounds of patient’s culture and education level.
+ Attention/concentration: The dreaded serial 7s or spelling a short word backwards (world, apple, whatever)
+ Reading/writing: Can they read a sentence and copy it?
+ Abstract concepts: Explain connections or similarities between objects or understand simple proverbs.
+ Insight: Is the patient aware of their mental illness? Do they blame it on someone else? Can be absent, limited, or normal.
+ Judgement: Does the patient understand the effect of their actions and decisions? Ex: what would you do if you found a wallet on the ground?