Overview of Assesment

Medical history + Social history + Mental status exam + lab/radiology/other resources + knowledge of differential diagnosis/biopsychosocial determinants = CASE FORMULATION

predisposing

precipitating

perpetuating

protective

1. establish rapport first
2. let the patient talk freely, within limits
3. determine chief complaint
4. develop provisional differential diagnosis
5. use both open and closed ended question
6. use focus questions to clarify provisional diagnosis
7. follow up vague replies
8. dont put of difficult questions
9. ask about suicide
10. give patient chance to ask questions
11. try to convey a sense of confidence and optimism

• beginning- ID self, purpose of interview, how long it will last
• middle- balance of btw our needs and patient needs
• end- thank them, let them ask questions, tell them when you see them again

• question from knowledge of diagnostic criteria and psychodynamics
• inquire about pertinent positives and negatives
• include general review of symptoms
• elicit patients understanding of problem

• contributes to understanding of biopsychosocial determinants
• allow both you and patient to begin to understand the patients current difficulties within context of their life

• goal- accurately record individuals mental functioning on day and time of interview and assist in clarifying diagnosis
• events
  • begin when you first meet patient and continue throughout interview (most of it is observational)
  • include both observations and information you obtain from questions

• general appearance, behavior, attitude
• level of consciousness and orientation
• speech and language
• mood and affect
• thought content, form, perceptions
• memory and congnition
• judgement, insight

Behavior: what we look for

• activity level
• eye contact
• any mannerisms
• stereotyped behavior, echopraxia (mimic what we do)
• aggressive/combative
• flexibility (mental, physical), rigidity

orientation and awareness: what we look for

• level of consciousness
• orientation to person, place, time, circumstance
• attention and vigilance

• speech- volume, rate, fluency, intelligibility, naming

Define thought form/process

Define judgement and insight

• judgement- patients cpapcity to make reasoned decisions
• insights- patients awareness and acknowledgement of factors that influence a given situation

• establish working alliance
• gather information leading to a provisional diagnosis and or differential diagnosis
• assess risk (ex: suicidality, substance abuse, mania, psychosis)
• initiate treatment