Doug Langbehn, M.D., Ph.D.
August 26, 1998
Identifying Information: Pts age, gender, cultural/ethnic background, marital status, and city of residence).
Chief Complaint: One or two sentence summarypreferably a quote from the patientregarding the reason treatment is being sought.
History of Present Illness (HPI): Present as coherent (and accurate!) of a story as possible describing the development of the problems that have led to the current episode of care. This includes the chronology and context of symptom development, most relevant contributing or complicating environmental factors (family stress etc.), previous treatment already tried for the presenting problem, and the mechanism by which the patient came to be here for treatment (referral, transfer form another hospital, admission from outpatient clinic, etc.).
The exact format for presenting the information in the HPI should not be considered rigid. Various stories can most logically be presented in various ways. It is important to think about a method of organizing this information that will allow the listener or reader to readily understand the situation and gradually build up a mental picture of the current clinical situation. At times, a strict chronological account will be appropriate. When a patient has multiple problems, it is sometimes easier to give a brief introduction indicating that there are multiple problems, then a chronological account of each problem, and finally a brief synthesizing summary of the inter-relationship between the problems.
Important information for the HPI may also seem like it belongs under one of the additional headings discussed below (e.g., medications, previous treatments, substance abuse, relevant social circumstances). If the information is especially relevant to the present illness, it should be introduced here. It is OK to simply remind the listener later on that this information exists and was presented in detail in the HPI. Be flexible, but try to have a method so that the information is filled in gradually and logically. It is especially annoying for the listener to only hear about a key bit of social or medical history after the initial mental impression of the problem has been formed from the HPI. (e.g., the patients wife just died, the evaluation was ordered because the patient is in legal trouble, the patient had a right frontal lobe stroke six months ago).
Medications and Allergies: All prescription and over-the-counter medications. Doses, length of time taken, who prescribed, side effects, and effectiveness of the medications are all important. If the patient states that he has an allergy to a medication, it is important to clarify what is meant. Often, patients merely mean that they had a bothersome side effect. These must be differentiated from true allergic reactions.
Past Psychiatric History: Detail all past treatments, including substance abuse treatment. Chronology (with approximate dates), past diagnoses, type of treatment, where treated, compliance with treatment, and results.
Past Medical History: List all significant illnesses, injuries, surgeries, and birth complications/defects. The same types of information as listed for Past Psychiatric History are important, but the information for other types of medical problems will often be less detailed.
Family History: Has anyone else in the family (including grandparents, aunts, uncles, cousins) had a psychiatric illness (including substance abuse)? How about other medical illnesses with a possible familial component (This includes not only classic "genetic" illnesses, but also things such as cardiovascular disease and many types of cancer.) Are any aunts or uncles mentioned genetically related to the patient? Is the patient adopted?
Social History: A wide variety of information about the patient falls into this category. Several methods of organization are possible. One reasonable approach is as follows:
Current Life Circumstances: Occupation or other means of financial support (disability, etc.), living arrangement, significant other(s) (including length of relationship), children, other sources of social support, financial responsibilities, legal problems, other difficult life circumstances leading to psychosocial distress.
Past Life History: Where born, family circumstances during childhood, education (including learning or behavioral problems during school), military history (branch of service, years of service, combat experience, discharge circumstances), occupational history, legal history (including childhood and adolescent delinquency), significant psychological trauma.
Habits: Smoking history, exercise, alcohol and drug use if not already discussed. Note that if the patient has a history of alcohol or drug problems, or significant use that may be contributing to the current problem, this should have already been mentioned in the HPI or past psychiatric history. This is probably the most common example of important information that is inappropriately deferred until too late in the presentation.
Review of Systems: Any physical complaints that the patient has. Normally, the physician will have inquired systematically about all organ systems. However, when presenting the case, only positive symptoms and negative symptoms of obvious relevance to the patients chief complaint or known medical problems are mentioned.
Physical Exam: Again, it is implicitly understood that the physician has performed a thorough examination of all body systems. Similar to the Review of Systems, only pertinent positive findings are mentioned in the presentation. (It is also traditional to comment on vital signs, even if normal. E.g., "Patients vital signs were stable and within normal limits, the rest of the physical exam was unremarkable.")
Mental Status Exam: Patients ability and willingness to cooperate with the exam/interview. Orientation, grooming, and general level of cognitive functioning/intelligence. Mini-Mental State score (If more detailed neuropsychological results were obtained, they may be listed at this point or later, as seems natural to the flow of information.). Level of psycho-motor activity. Speech, including latency, pressure, signs of formal thought disorder, aphasia, or dysarthria. Mood (A symptomWhat the patient states their internal affective state is.) Affect (A signwhat the observer infers the patients internal affective state is based on their appearance), Thought contentpsychotic symptoms (hallucinations, delusions), suicidal, homicidal, or other violent ideation. Insight (understanding of illness and the reasons that they have come to treatment). Judgement (ability to make reasonable decisions, especially with regard to their activities of daily living).
Note: Often, key parts of the Mental Status Exam, especially psychotic symptoms or violent ideation, will have been described in detail in the HPI. It is perfectly acceptable to merely make a brief reminder of these when the subject again arises in the mental status exam.
Axes I-V as defined in DSM IV.
Discussion and Plan: Briefly discuss the synthesis of the information presented that led to the diagnoses listed under Assessment. Reference to DSM criteria should be made. If diagnostic issues are unclear, discuss the differential diagnosis and the relative support that the evidence presented lends to each hypothesis. Often, a patient will technically qualify for multiple DSM diagnoses, although it is probable that they are really only suffering from one or two underlying pathological processes. If this if the case, it should be noted. (Remember that DSM generally describes clinical syndromes, not illnesses).
Discuss treatment recommendations and the rationale for these over other alternatives. Remember that treatment may encompass medications, psychotherapy, psychosocial interventions, rehabilitation programs, patient and family education, and follow-up and after-care planning (How can we help prevent this problem from happening again?)