OSCE – Psych

Comprehensive Psychiatric Assessment

ID:

  • age, sex, source, reliability, marital status (single/common-in-law/married), ethnicity, culture/religion (optional), children, employment status, living situations)

Mode of Presentation (ie brought in by EHS? by police?)

HPI: pt’s current concerns – often require collateral info – family, friends, neighbors, police

  • Onset, duration, frequency, Character, Intensity, associated events, provocative/palliative factors

Psychiatric symptom Screen

  • Normalize symptoms before asking, eg. “some people tell me that when you watch TV, they get special message from God. Have you ever experienced something like that?”

Depression – M SIGE CAPS

  • Mood
  • Sleeplessness
  • Interest – lost of interest (anhedonia)
  • Guilt
  • Energy – decreased
  • Concentrate – unable to
  • Appetite – loss of appetite
  • Psychomotor retardation (“do you feel as if you are slowed down?”)
  • Suicidal Ideation

Mania – DIG FAST

  • Distractibility and easy frustration
  • Impulsivity – Irresponsibility and erratic uninhibited behavior
  • Grandiosity – esteem inflation
  • Flight of ideas – racing thoughts
  • Activity increased with weight loss and increased libido
  • Sleep is decreased – insomnia
  • Talkativeness – Pressured Speech

Psychosis

  • Hallucination:
    • “Do you ever see things or hear things that other people don’t see or hear?”
    • “Do you ever feel as if something is crawling or creeping on your skin?”
  • Delusions:
    • “Do you ever feel as if people are talking about you of laughing at you behind your back?”
    • “Do you feel as if anyone or anything is out to get you?”
    • “Do you ever get special messages while watching TV or reading newspaper that are intended especially for you?”
    • “Do you ever get the sense that other people can read your thought or that thoughts are being inserted into your mind against your will?”
  • Negative symptoms: flat affect, alogia, avolition
  • disorganized speech

Anxiety

  • Panic attacks
  • OCD:
    • “Are you ever bothered by persistent thoughts that you cannot get out of your mind?”
    • “Do you ever feel the ned to repeat certain activities over and over again even though you don’t want to?”
  • PTSD – recent traumatic event

SI/HI


Substance abuse / dependence: Tobacco? Alcohol? Drug use?

  • What age did you start taking drugs?
  • What was the first drug you tried?
  • What is your drug of choice now? How much?
  • Previous attempts to quit (ie. Detox)
EtOH: “tell me about your drinking?” CAGE
  • Cut down: “Have you ever tried to cut down on your drinking?”
  • Annoyed by criticism: “Are you annoyed by criticism about your drinking?”
  • Guilty about drinking: “Do you ever feel guilty about drinking?”
  • Eye-opener: “Do you ever need to drink first thing in the morning?”

Past psychiatric history:

  • dx & Tx, age at onset,  Current psychiatrist?
  • past psychiatric admissions (#), most recent admission,
  • past suicide attempts, ECT/LAI tx?

Family Hx: psychiatric illnesses, medical illnesses – pedigree

PMH/PSH/Med/Allergies

Social Hx: see psychosocial Hx

ROS 


Psychosocial Hx

Born in: ___________(Where were you born and raised?)

  • Were there any problems that you know of with your mother’s pregnancy or delivery?
  • Did you reach developmental milestones on time?

Childhood?Include Family structure ( ie. Parents divorced/separated? # of siblings?)

  • Whom did you feel close to while you were growing up?
  • What was your family like?
  • Was there any violence in your home?
  • Did you encounter any abuse (verbal, physical, sexual)?

Schooling Years include grade completed? hx of bullying?

  • When did you start school? Did you like school? Did you have any trouble in school?
  • What were you like as a child? As a teenager?

Current living situation? Marital status? Kids? Relationship Hx? Sexual Hx?

  • Do you have any children of you own? How would you describe your relationship with your children?
  • How would you describe your relationship with your family now?
  • Do you have any close relationship right now? Tell me about that.
  • Are you or have you been married? How would you describe your marriage?
  • Where do you live now? What is your home like?

Employment Hx and current status?

  • Are you working right now? Tell me about your job or your trade? 
  • What kinds of jobs have you had in the past? 
  • What kinds of things do you do for fun? 
  • How satisfied are you with your life right now? 

Forensic hx

  • Previous jail sentences? Criminal Record? Outstanding Charges?

Mental Status Exam – ASEPTIC

Appearance and Behaviour:

  • Actual vs apparent age
  • Attire, hygiene, makeup, jewelry, clothing, body habitus, distinctive physical features – physical abnormalities, tattoos/piercings etc
  • Noting body language (elaborate hand gestures), mannerisms (lip smacking), attentiveness, psychomotor retardation / agitation, responding to cues in the room (VH/AH)
  • Agitation, hyperactivity, akathisia, compulsions, tics, tremor

Speech:

  • rate and volume (loud, soft), how pt answers questions, tone – accent?
  • Flow- pressured vs increased latency?
  • Cooperation: eye contact, attentiveness to interview?, attitude/demeanour, secondary gain

Emotion:

  • Mood – elicit the pt’s description of his mood – dysphoric, euphoric, anxious, angry
  • Affect – range & stability, intensity (flat vs blunted, labile, full/wide range, inflated)

Perception – hallucination and illusion

Thought content and process

  • Thought process/form – inferred from the pt’s speech – coherent? logical progressions? – linear, tangential, circumstantial, loose association, perseveration, flight of ideas, thought blocking, word salad, echolalia
  • Thought content – delusions (erotomanic, grandiose, paranoid) vs overvalued ideas, obsessions, phobias, SI/HI

Insight & judgement

  • Insight – document whether the pt has any insight into his illness
    • does the pt recognized that something is wrong?
    • Do they accept the problem is due to illness?
    • Are they willing to accept medical advice regarding management?
  • Judgement – ask pt to respond to some questions. Eg. “What would you do if you woke up in your home and found it to be on fire?”

Cognition –

  • LOC, Oriented to person, place, time.
  • MMSE, attention/concentration (spell WORLD backwards), calculations (serial 7’s), abstraction (proverb interpretation)

 Reference:

  • OSCE and Clinical Skills Handbook – second edition
  • The Edmonton Manual of Common Clinical Scenarios

 

 

 

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