PSYCHIATRY

INTRODUCTION

The Psychiatry rotation is five weeks long, divided into two-week and three-week sub-blocks. The majority of time in Birmingham will be spent at the Center for Psychiatric Medicine (CPM). Students take call four times over the five weeks, and weekends are off unless you are on call.

Initial Psychiatric Evaluation

1. Identifying data (28 yo WF)

2. Informant (patient, family member, spouse)

3. Chief complaint

4. HPI

5. Past medical history

6. Past surgical history

7. Past psychiatric history (include previous hospitalizations, diagnoses, treatments, ECTs, etc.)

8. Social and family histories

9. ROS

10. Mental Status Exam

a. Appearance, Behavior, Attitude

i. General Appearance (apparent age, peculiarity of dress, cleanliness, cosmetics)

ii. Motor Status (posture, gait, gestures, tics, grimacing, tone, tremors, picking, mannerisms)

iii. Activity (over or underactive, purposeful or disorganized, stereotyped, graceful, echopraxia)

iv. Facial Expression (alert, tense, worried, sad, happy, dreamy, frightened, in pain, angry, sneering, ecstatic, laughing, smiling, suspicious)

v. Behavior (indifferent, frank, friendly, embarrassed, seeking help, evasive, afraid, resentful, sullen, angry, irritable, assaultive, erotic, negativistic, denudative, exhibitionistic, dramatic, impulsive)

b. Mood and Affect

i. Mood (subjective emotional state – how the patient feels)

ii. Affect (observed emotional state – your evaluation of the patient’s emotional state)

c. Stream of Thought and Speech

i. Speech (soft or loud, stuttering, hesitant, accent, enunciation)

ii. Speed and Quality (rate of speech, delay, variation with different topics)

iii. Stream of Thought (coherent or incoherent, illogical, vague, loosely organized, neologisms)

d. Content of Thought

i. Delusions (delusions of reference, delusions of alien control, special messages, nihilistic delusions, delusions of self-depreciation, delusions of grandeur, somatic delusions)

ii. Hallucinations (auditory, visual, olfactory, gustatory, tactile, feelings of depersonalization)

iii. Obsessions and Compulsions

iv. Fantasies and Daydreams

v. Thoughts of Violence (suicide, homicide, specific plans)

e. Insight (patient’s understanding of significance of symptoms and situation)

f. Judgment (patient’s past decisions and plans for the future)

g. Cognitive Exam (MMSE)

11. Physical Exam

12. Labs/Studies

13. Assessment (All 5 Axes)

Mini-Mental Status Exam
What is the year, season, month, day, and date?	1 point each, total = 5
What state, county, town, and hospital are we in? What floor are we on?	1 point each, total = 5
Name three objects. Ask the patient to repeat all three after you say them. Repeat them until the patient knows them, and ask the patient to remember them for later.	1 point for each correct answer, total = 3
Ask the patient to count backwards by 7 from 100 (93, 86, 79, 72, 65). Stop after five answers. Alternatively, ask the patient to spell “world” backwards.	1 point for each correct answer, total = 5
Ask for the three objects mentioned earlier.	1 point for each correct answer, total = 3
Ask the patient to name two items, like a watch and a pencil.	1 point each, total = 2
Have the patient repeat the following sentence: “No ifs, ands, or buts.”	1 point
Ask the patient to follow a three-step command: “Take this piece of paper in your right hand, fold it in half, and put it on the floor.”	1 point for each command, total = 3
Write “Close your eyes” on a piece of paper, and ask the patient to read it and do what it says.	1 point
Ask the patient to write a sentence.	1 point if it contains both a subject and a verb
Draw a pair of intersecting pentagons and ask the patient to copy it.	1 point
Record the score as a total out of 30 points, and note which parts the patient missed.	Total = 30

Symptoms of Depression

S = Sleep (increased or decreased amount)

I = Interest (decreased)

G = Guilt

E = Energy (decreased)

C = Concentration (impaired)

A = Appetite (increased or decreased)

P = Psychomotor Retardation

S = Suicidal Ideation

Symptoms of Bipolar Disorder

Distractability

Insomnia (dec. need for sleep)

Grandiosity

Flight of ideas

Activitiesàinc. goal oriented activities, impulsive

Speechàpressured, rapid

Thought processàracing thoughts