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CMN 548 Module 1 Study Guide 2025 Practice
1. GUIDE SADOCK
Chapter 7.1 - 7.2,
Identifying data Topic
Identifying data Questions
Identifying data Comments and helpful hints
Chief complaint (CC) topic
Chief complaint (CC) questions
Chief complaint (CC) comments and helpful hints
History of pre- sent illness (HPI):
History of pre- sent illness (HPI): questions
History of pre- sent illness (HPI):
Complete the following table which outlines the elements of the initial psychiatric interview:
Name, age, sex, marital status, religion, education, address, phone number, occupation, source of referral
Be direct in obtaining identifying data. Request specific answers.
If patient cannot cooperate, get information from family member or friend; if referred by a physician, obtain medical record.
Brief statement in patient's own words of why patient is in the hospital or is being seen in consultation
Why are you going to see a psychiatrist? What brought you to the hospital? What seems to be the problem?
Record answers verbatim; a bizarré complaint points to psychotic process.
Development of symptoms from time of onset to present; relation of life events, conflicts, stressors: drugs; change from previous level of functioning
When did you first notice something happening to you? Were you upset about anything when symptoms began? Did they begin suddenly or gradually?
Record in patient's own words as much as possible. Get history of previous hospi- talizations and treatment. Sudden onset of symptoms may indicate drug-induced disorder.
CMN 548 Module 1 Study Guide 2025 Practice
comments and helpful hints
- Previous psychi- atric and medical disorders:
- Previous psychi- atric and medical disorders: QUES- TIONS
- Previous psychi- atric and medical disorders: com- ments and help- ful hints
- substance use/abuse
- Past medical his- tory
- Family History (FH): topic
Psychiatric disorders; psychosomatic; medical, neurologic illnesses (e.g., cranio- cerebral trauma, convulsions).
Did you ever lose consciousness? Have a seizure?
Ascertain extent of illness, treatment, medications, outcomes, hospitals, doctors. Determine whether illness serves some additional purpose (secondary gain).
Substance use disorders can mimic or induce psychiatric syndromes, elevate risk of suicide and violence, and have important impact on safe medication prescribing.
Various tools can be used to aid in gathering the substance use history. Examples include the commonly used CAGE questionnaire which has been modified to include other drugs (and now called CAGE-AID)
The interviewer is interested in obtaining an accounting of major medical disor- ders both to develop a complete history and to identify illness that could mimic a psychiatric disorder, contribute to the context of the presentation or factor into treatment planning.
Psychiatric, medical, and genetic illness in mother, father, siblings; age of parents and occupations; if deceased, date and cause; feelings about each family member,
CMN 548 Module 1 Study Guide 2025 Practice
- review of sys- tems: mood Hy- pomania/mania
- review of sys- tems: anxiety
- review of sys- tems: psychosis
- review of sys- tems: obses- sive-compulsive
- review of sys- tems: trauma
- review of sys- tems: behavior
- mental status exam
Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidality).
Hypomania/Mania: elevated, expansive or irritable mood, decreased need for or inability to sleep, excessive energy, marked increase in goal and pleasure directed activity, increase amount and pace of speech and thought, grandiosity, heightened libido, impulsivity and/or recklessness in behaviors such as spending and sex
Anxiety Experience of panic attacks, somatic symptoms of anxiety, phobic, or social avoid- ance
Experience of hallucinations, delusions, disorganized behavior, speech or thought, negative symptoms
Repetitive intrusive and unwanted thoughts, compulsive behaviors to neutralize anxiety, hoarding behaviors
Traumatic exposure; intrusive and avoidance symptoms, negative alterations in cognitions and mood, excessive arousal and reactivity
Substance use, gambling, impulse control problems, disordered eating, repetitive self-harm
The MSE is the functional equivalent of the physical examination in other areas of medicine.
It is a systematic collection of the observations (e.g., signs such as blunt af- fect or rapid speech) and reported mental experiences (e.g., symptoms such as depressed mood or hallucinations) that produce a picture of the patient's current mental state. The interviewer makes these observations throughout an
CMN 548 Module 1 Study Guide 2025 Practice
encounter and ultimately documents the findings together in the MSE section of the evaluation document.
- physical exam Psychiatrists do not usually personally conduct comprehensive physical exami- nations but may conduct focused examinations such as neurological or thyroid examinations. In the outpatient setting, the psychiatrist generally relies on the PCP to conduct the physical examination and it is useful in the initial evaluation to record the date of the most recent physical examination and review of recent laboratories if results are available.
- plan formulation The formulation should include a brief summary of the relevant findings from the history and examination including the psychosocial contexts in which the problem has developed and comments on the relevant contributions to the presentation of personality function, medical problems, social stress, and other social and cultural factors.
Finally, the formulation should include a summary of the risk assessment with estimates of acute and long-term risk of suicidal or violent behavior and opinion about the appropriate level of care that will lead to a safe and successful outcome.
- treatment plan When evaluation produces treatment recommendations, these are typically shared with the patient at the conclusion of the encounter in a manner consistent with the patient's capacity to receive and process the information and with explicit discussion of matters relevant to informed consent for recommended treatment.
Treatment discussions typically involve a good deal of psychoeducation about diagnosis, the nature, risks, and benefits of recommended treatments and infor- mation that addresses stigma and adherence.
It is wise to involve significant others in these conversations especially if there are concerns that the patient may need assistance in processing information and making decisions to ensure that decisions are consistent with the patient's best interest.
CMN 548 Module 1 Study Guide 2025 Practice
- What are some common mis- takes made by beginners in ob- taining the histo- ry of present ill- ness?
- What are some examples of questions that can be asked to obtain a history of present illness when the patient is in a crisis?
- How would you approach a pa- tient when ob- taining a history of present illness when you're sim- ply trying to ex- plore symptoms?
- What are some key points to re- member in con- ducting a well executed inter- view?
The most common pitfall for beginners is spending too much time on the HPI
What has been happening over the past week or two that has brought you into the clinic?
Have there been any events that you think have caused your problem or made it worse?
Have you sought any treatment for this problem?
Many patients automatically jump into a chronologic narrative of their problems when prompted by one of the preceding questions.
If this happens, it is a time to fall silent for a while and listen. Remember, this is your "scouting period" (see Chapter 3), during which you are observing, listening, and hypothesizing. However, if your patient begins to jump around into other issues or time frames, you may want to refocus him.
At its best, a well-conducted interview resembles a dance in which the give and take between clinician and patient flow ettortlessly throughout the hour, giving the patient the sense that he just participated in a fascinating conversation about his life rather than a "psychiatric" interview.
One way to set the stage for this type of experience is to begin the interview by
CMN 548 Module 1 Study Guide 2025 Practice
- Why is it im- portant to ob- tain the history of present illness in a chronologi- cal fashion?
- What are some examples of ways to keep pa- tients on track when obtaining the history of present illness?
- Why is it impor- tant to focus on symptoms as the patient mentions them during the interview?
- Why is it impor- tant to have an
showing genuine interest and curiosity about the patient's job, hobbies, or life situation and to allow the patient to steer the discussion toward clinical topics.
Ensuing questions track the course of the illness through months or years, arriving eventually at the present.
Patient: I felt so angry when my wife yelled at me. But she's always been that way. Back when I was in law school, she nagged at me constantly. I'd have to spend late nights at the law library, and she refused to understand.
Interviewer: I'd like to hear more about that period later, but right now let's focus on what's been happening over the last 2 weeks or so. You said you got angry at her. What happened then?
Here, the interviewer stays on the depression topic by cueing ott what the patient has said about work (see the discussion of the smooth transition in Chapter 6).
If the interviewer had not actively structured the interview this way, the patient might have discussed details of his work environment that would be less relevant to the diagnosis of major depression.
Later, when ascertaining the social history, the interviewer can refer to what the patient said about work.
Asking about current versus baseline functioning is important diagnostically.
understanding of The^ classic^ example^ is^ the^ ditterence^ between^ schizophrenia^ and^ bipolar^ dis- how the patient was functioning
order. In schizophrenia, the patient's level of functioning gradually decreases over months or years, whereas in bipolar disorder, the patient may have been
CMN 548 Module 1 Study Guide 2025 Practice
chiatric history take to com- plete?
- Complete the following table which summa- rizes the compo- nents of the psy- chiatric history
- Age of onset of symptoms
- Premorbid func- tioning
- Subsequent episodes of illness
Knowing the age at onset may help you to decide between potential diagnoses, with anxiety disorders having a much earlier onset than either mood disorders or schizophrenia
p. 94, 90- To assess overall functioning, ask about the three basic aspects of life: love, work, and fun. Love includes all-important relationships: family, spouse, and close friends.
In addition to paid employment, work includes school, volunteer activities, and the structured day activities in which many chronically mentally ill patients participate. Fun refers to hobbies and recreational pursuits.
94- 95
Include questions about the severity of episodes and exacerbation, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes
of mania or exacerbation of schizophrenia often correspond with hospitaliza- tions. As with hospitalizations, a time-eflcient method of asking about episodes is to ask
CMN 548 Module 1 Study Guide 2025 Practice
- Treatment histo- ry
- Treatment Histo- ry 2
about the first one, the latest one, and the total number of episodes.
When did you have your first breakdown?
How many have you had in total?
When was your last one?
95
You ask about prior treatments mostly to help with future treatment decisions but also to help nail down a diagnosis. For example, if lithium was helpful for an attective episode, bipolar disorder would be high on your list. You want to know what has been tried in the past and whether it has worked. Accuracy and detail are important here, because a sloppy treatment history can lead to poor future treatment decisions. For example, patients may be falsely labeled "treatment resistant" on the basis of old records indicating that numerous medications were "tried but were unsuccessful." On closer questioning, such patients may in fact have had few adequate trials of medication.
I suggest the following format for obtaining the treatment history:
General questions Current caregivers Hospitalization history Medication history Psychotherapy history
Use the mnemonic Go CHaMP so that you don't miss any category. You won't necessarily ask your questions in the above order—in fact, you will obtain much of this information during the HPI—but it's helpful to think about these five aspects of the treatment history to make sure that you haven't neglected
In addition to asking these questions, it is often useful to ask why your patient was hospitalized:
In general, what sorts of things have caused you to need to be in the hospital?
Your assumptions about reason for hospitalization may be wrong, as illustrated by the following example CLINICAL VIGNETTE A patient with chronic schizophrenia stated that he'd been hospitalized several times over the past 2 years. The resident initially assumed that these hospital- izations were for psychotic de-compensations, but when asked, the patient said that most were alcohol detoxification admissions. This prompted the resident to obtain a much more thorough substance abuse history than he had planned.
- Medication histo- 97- ry
- Medication His- tory
The most important limit on the bio-availability of medication has nothing to do with pharmacodynamics or pharmacokinetics; rather, it is patient noncompli- ance.
Have you been on medications for your depression?
For how many weeks did you take your medications?
To the extent possible, document all the medications the patient has tried. Many patients will not remember generic names or may only remember what the pill looked like or the side ettect it caused.
Obviously, the more you know about alternative names, shapes, and side ettects of medication, the more eflciently you will be able to obtain this history.
I find smartphone apps such as Epocrates to be helpful, because they have photographs of medications, which help patients identify them.
For psychologists and social workers, a number of books have been published that teach the basics of psychopharmacology to non-MDs, and I recommend that you become familiar with this information.
Many psychiatric medications take several weeks to have a therapeutic ettect. Antidepressants take 4 to 6 weeks. Antipsychotics may take 1 to 2 weeks or longer, depending on the clinical situation. Thus, merely documenting that a patient has tried a particular medication does not mean that he's had an adequate trial.
At this point, a normalizing question may be helpful:
Often, people do not necessarily take their medications every day but will take them every so often, depending on how they feel. Was that true for you?
HOW ACCURATE ARE PATIENTS WHEN RECALLING PRIOR TREATMENTS? A fascinating study examined this clinically relevant but underexplored question (Posternak and Zimmerman 2003). An independent evaluator interviewed 73 patients who had been treated in an academic psychiatric clinic for an average of 3.5 years. After the interview, researchers reviewed clinic charts to determine how accurately the patients recalled their antidepressant trials. The results? They did pretty well, overall, recalling 80% of the monotherapy (single medication) trials over the prior 5 years. However, they only remembered 26% of augmentation trials (i.e., when a second medication is added to the first to boost the response). And augmentation trials that were over 2 years old were not remembered by anybody. The bottom line is that your patient will accurately recall medications tried if the regimen has always been simple, but those who have taken combinations of medications will be much less reliable.
CLINICAL VIGNETTE A resident was doing a psychopharmacologic
evaluation of a 46-year-old married Latino woman with a several-year history
- psychotherapy history
he received. You can compensate for this by describing the therapy.
Did your therapist focus on "automatic thoughts" that make you more anxious or depressed?
Did she give you homework assignments between sessions?
Did she have you practice doing
things that caused you anxiety? (For cognitive-behavioral therapy.)
Did your therapist focus on your childhood experiences and how those attect your current life? (For psychodynamic therapy.)
You can also ask a more open-ended question:
Without going into too much detail, what sorts of things did you focus on in therapy? Was your therapist a psychologist, a psychiatrist, or a social worker?
Knowing this may or may not be useful. For example, a patient may say she had a therapist, when in fact she was seen by a psychiatrist once a month for brief visits. This was more likely psychopharmacologic management than psychotherapy.
How did you like working with your therapist?
Was the therapy helpful?
In what ways was it helpful?
This information will be particularly valuable in assessing the patient's suitability for further therapy.
How did you leave treatment?
- Why is it impor- tant to screen for general medical conditions when conducting a psy- chiatric interview
- screen for gener- al medical condi- tions: medication
- screen for gener- al medical condi- tions: History of medical illness
- screen for gen- eral medical con- ditions: primary care provider
The way a patient ended treatment may tell you much about how he viewed treatment and may help you plan how to proceed with your own treatment of the patient. Some patients, for instance, have a history of ending therapy by simply not showing up for the next session. Others may have had a stormy termination. Others may have terminated "by the book" but continue to feel unexpressed sad or angry feelings toward the therapist.
Medical conditions can attect psych conditions p
ascertain the patient's inherited risk of developing a psychiatric or medical disor- der
Obtain a list of all medications, including those for general medical conditions. Ascertain whether the patient has been taking them as prescribed.
You can begin with a screening question such as Do you have any medical problems? Have you ever had a medical illness? However, a common problem with this approach occurs when the patient says "no" without thinking carefully, as the following vignette illustrates.
In the preceding vignette, asking about illness elicited invalid information. One way to increase the validity of your medical history questions is to first ask if the patient is being seen by a doctor. Do you see a doctor regularly? What does he/she treat you for? By referring to a relationship with a caregiver, you will typically jog the patient's memory for past diagnoses and treatments. You can also learn information about
- screen for gen- eral medical con- ditions: surgical history
- screen for gener- al medical condi- tions: review of systems
- MIDAS mnemon- ic
even if she could benefit from it. A more accurate statement would be, "Haldol causes dystonia." This leaves the door open to trials of other neuroleptics.
It is important to ask specifically about previous surgery; many patients do not volunteer this information when asked about "medical problems," either because it was too long ago or because they do not consider an operation to have indicated a medical problem per se. CLINICAL VIGNETTE A 54-year-old man with major depression had mentioned gastritis as his only medical problem. Midway through the interview, he mentioned in passing, "I divorced my wife back in '84 or so, just after they took out part of my pancreas." On further exploration, the patient considered that operation to be a turning point in his life, because he made the decision to stop drinking then and had been sober since.
The purpose of the review of symptoms is to note medical problems that the patient may have forgotten to describe in response to the MIDAS questions. Whether it's necessary to do a review of symptoms for every patient is a matter of controversy.
The MIDAS questions may miss seemingly minor symptoms that may be the first clues to a big problem, such as the occasional cough that signals lung cancer.
But the review of symptoms takes a lot of time, and most mental health clinicians refer their patients to an internist for physical examinations anyway. Here's a compromise.
I'll outline two approaches to the review of symptoms, a brief review of symptoms (1 minute) and a more extended one (5 minutes) (Table 16.1). Which approach is better depends on the patient and the clinical setting?
Screening Questions
- Why is it im- portant to obtain the family psychi- atric history dur- ing the psychi- atric interview?
- What type of useful informa- tion can you gain from the family psychiatric histo- ry.
- What are some key points to ad- dress during the bare-bones ap- proach to the family psychiatric history?
Mnemonic: MIDAS Do you take any medications now? Do you have any medical Illnesses? Do you have a primary care Doctor? Have you ever had Allergies, reactions, or side ettects from any medications? Have you ever had any Surgery? Medical review of systems.
Recommended time: 3 minutes
Helps us to determine if patient is at risk for disorders significantly tied to genomic transmission p
Establish patient's risk for disorders tied strongly to familial transmission p111-
Table 17.
Ask if any blood relative has diagnosed psychiatric, medical, or neurological disorders p110-
