What components should be included in a complete psych (psychiatric) H&P (history and physical) questionnaire?

Components of a Complete Psychiatric History and Physical Examination

A complete psychiatric H&P questionnaire should include a comprehensive assessment of psychiatric history, medical history, personal and social history, mental status examination, and physical examination components as outlined by the American Psychiatric Association practice guidelines.

History of Present Illness

• Chief complaint and reason for evaluation 1
• Psychiatric review of systems, including anxiety symptoms and panic attacks 1
• Assessment of sleep abnormalities, including sleep apnea 1
• Assessment of impulsivity 1

Psychiatric History

• Past and current psychiatric diagnoses 1
• Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide 1
• Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts) 1
• Prior suicidal ideas, suicide plans, and suicide attempts, including:
  • Aborted or interrupted attempts
  • Details of each attempt (context, method, damage, potential lethality, intent) 1
• Prior intentional self-injury without suicidal intent 1
• Treatment history:
  • History of psychiatric hospitalizations and emergency department visits 1
  • Past psychiatric treatments (type, duration, doses) 1
  • Response to past psychiatric treatments 1
  • Adherence to past and current treatments 1

Substance Use History

• Use of tobacco, alcohol, and other substances (marijuana, cocaine, heroin, hallucinogens) 1
• Misuse of prescribed or over-the-counter medications or supplements 1
• Current or recent substance use disorder or change in use 1

Medical History

• Allergies or drug sensitivities 1
• All current and recent medications, including side effects 1
• Relationship with primary care provider 1
• Past or current medical illnesses and related hospitalizations 1
• Relevant past or current treatments (surgeries, procedures, complementary/alternative treatments) 1
• Neurological or neurocognitive disorders or symptoms 1
• Physical trauma, including head injuries 1
• Sexual and reproductive history 1
• Additional medical history to consider:
  • Cardiopulmonary status
  • Endocrinological diseases
  • Infectious diseases (STDs, HIV, tuberculosis, hepatitis C)
  • Conditions associated with significant pain 1

Family History

• History of psychiatric disorders in family members 1
• For patients with current suicidal ideas: history of suicidal behaviors in biological relatives 1
• For patients with aggressive ideas: history of violent behaviors in biological relatives 1

Personal and Social History

• Psychosocial stressors (financial, housing, legal, occupational, interpersonal problems) 1
• Social support assessment 1
• Trauma history 1
• Exposure to violence or aggressive behavior (combat exposure, childhood abuse) 1
• Legal or disciplinary consequences of past aggressive behaviors 1
• Cultural factors related to social environment 1
• Need for interpreter 1
• Personal/cultural beliefs and cultural explanations of psychiatric illness 1

Physical Examination

• General appearance and nutritional status 1
• Coordination and gait 1
• Involuntary movements or abnormalities of motor tone 1
• Sight and hearing 1
• Vital signs 1, 2
• Height, weight, and body mass index (BMI) 1
• Skin examination, including stigmata of trauma, self-injury, or drug use 1

Mental Status Examination

• Speech assessment (fluency and articulation) 1
• Mood and level of anxiety 1
• Thought content and process 1
• Perception and cognition 1
• Assessment of hopelessness 1
• Current suicidal ideas, plans, and attempts, including:
  • Intended course of action if symptoms worsen
  • Access to suicide methods including firearms
  • Possible motivations for suicide
  • Reasons for living
  • Quality of therapeutic alliance 1
• Current aggressive or psychotic ideas 1

Laboratory Testing

• Targeted laboratory testing based on clinical presentation rather than routine extensive testing 1, 2
• Consider the following tests when clinically indicated:
  • Complete blood count (CBC)
  • Basic/comprehensive metabolic panel
  • Thyroid function tests
  • Urinalysis
  • Urine toxicology screen 2

Special Considerations for Specific Patient Groups

• Patients over 65 years: More comprehensive laboratory evaluation including B12 levels 2
• First-episode psychosis: Comprehensive evaluation to rule out medical causes 2
• Patients on psychotropic medications: Therapeutic drug monitoring 2
• Patients with abnormal vital signs: More extensive workup 2
• Patients with disorientation or confusion: Consider neuroimaging 2

Common Pitfalls to Avoid

• Overreliance on routine laboratory testing without clinical indication can lead to unnecessary delays in treatment 1, 2
• Attributing symptoms to psychiatric causes without adequate medical workup 2
• Failure to recognize medication side effects or interactions 2
• Not considering neurological conditions that can present with psychiatric symptoms 1
• Missing metabolic and endocrine conditions that can induce mental health symptoms 1

By systematically addressing all these components in a psychiatric H&P questionnaire, clinicians can ensure a comprehensive evaluation that addresses both psychiatric and medical aspects of patient care, leading to appropriate diagnosis and treatment planning.