What are the steps to conduct a psychiatric history and physical (H&P) examination?

How to Conduct a Psychiatric History and Physical Examination

Begin by obtaining vital signs and a focused physical examination targeting neurologic, cardiac, and respiratory systems, as these have a 14.9% yield for detecting conditions requiring management changes and are where life-threatening conditions most commonly present as psychiatric symptoms. 1

Initial Assessment Framework

The psychiatric H&P is not a single encounter but rather an information-gathering process that may require multiple meetings with the patient, family, or collateral sources before completion. 2 The evaluation serves two critical functions: determining if psychiatric symptoms are caused by underlying medical conditions requiring acute treatment, and identifying comorbid medical conditions that could benefit from immediate intervention. 1

Identifying Information and Chief Complaint

• Document patient demographics (name, age, gender, date of birth), date/time of evaluation, and source of information (patient, family, medical records). 3
• Record the patient's own words regarding the presenting problem and circumstances leading to evaluation. 3

History of Present Illness

Conduct a systematic psychiatric review of systems rather than relying solely on the patient's volunteered complaints, as patients frequently minimize symptoms or lack insight. 1

Required Components:

• Anxiety symptoms and panic attacks 2, 1
• Sleep patterns and abnormalities, including sleep apnea 2, 1
• Assessment of impulsivity 2, 1
• Temporal pattern: Establish sequential order of onset, frequency, tempo, and nature of change over time—new-onset or acute changes warrant more extensive medical evaluation. 1
• Impact on activities of daily living (ADLs and IADLs) 1
• Plausible relationships between events and symptoms, including potential triggers or contextual features. 1

Critical Collateral Information:

Obtain reliable information from an informant (care partner) regarding changes in cognition, daily function, mood, and sensorimotor function, as informant reports provide added value beyond patient self-report. 1

Psychiatric History

Suicidality Assessment:

• Prior suicidal ideas, suicide plans, and suicide attempts, including attempts that were aborted or interrupted. 2
• Details of each attempt: context, method, damage, potential lethality, and intent. 2
• Prior intentional self-injury without suicidal intent 4
• For patients with current suicidal ideas: assess history of suicidal behaviors in biological relatives. 4

Violence and Aggression Assessment:

• Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide. 2
• Prior aggressive behaviors: homicide, domestic violence, workplace violence, other physically or sexually aggressive threats or acts. 2
• Legal or disciplinary consequences of past aggressive behaviors 4
• For patients with current aggressive ideas: assess history of violent behaviors in biological relatives. 4

Treatment History:

• Past and current psychiatric diagnoses 2
• History of psychiatric hospitalizations and emergency department visits 4, 1
• Past psychiatric treatments (type, duration, and doses where applicable) 4, 1
• Response to past psychiatric treatments 4, 1
• Adherence to past and current pharmacological and non-pharmacological treatments 4, 1

Substance Use History

Assess all substances systematically, as substance intoxication can mimic or alter psychiatric symptoms and delay proper disposition. 2

Required Assessment:

• Tobacco, alcohol, and other substance use 4, 1
• Misuse of prescribed or over-the-counter medications or supplements 4, 1
• Current or recent substance use disorder or change in use 1
• Specific substances: alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, and other drugs of abuse. 1

Special Consideration for Intoxication:

The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis on which you begin the psychiatric assessment. 2 Consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves. 2

Medical History

Medication and Allergy Documentation:

• Allergies or drug sensitivities 4
• All current and recent medications (prescribed, non-prescribed, supplements), including side effects. 4, 1
• Recent medication changes and potential for withdrawal syndromes 1

Medical Conditions:

• Relationship with primary care provider 4
• Past or current medical illnesses and hospitalizations 4
• Relevant past or current treatments, including surgeries 4
• Past or current neurological or neurocognitive disorders 4
• Physical trauma, including head injuries 4
• Sexual and reproductive history 4
• Recent medical illnesses: infections, metabolic disturbances, endocrine disorders. 1

System-Specific Assessment:

• Cardiopulmonary status 3
• Endocrinological disease 3
• Infectious diseases: STDs, HIV, tuberculosis, hepatitis C. 3

Family History

• Psychiatric disorders in biological relatives 3
• History of suicidal behaviors in relatives (especially for patients with suicidal ideation) 4, 3
• History of violent behaviors in relatives (especially for patients with aggressive ideation) 4

Personal and Social History

• Psychosocial stressors: financial, housing, legal, occupational, interpersonal problems. 4, 3
• Trauma history 4, 3
• Exposure to violence or aggressive behavior 4
• Cultural factors related to the patient's social environment 4
• Patient's need for an interpreter 4
• Individualized risk factors for cognitive decline, including potentially modifiable factors. 1

Physical Examination

Abnormal vital signs are among the most important predictors of underlying medical pathology. 1

Required Measurements:

• Vital signs (temperature, blood pressure, heart rate, respiratory rate) 3, 1
• Height, weight, and BMI 3

Critical System Examination:

Prioritize three systems where life-threatening conditions commonly present as psychiatric symptoms: 1

• Neurologic system: focal deficits, gait abnormalities, tremor, rigidity. 1
• Cardiac system: murmurs, irregular rhythms, signs of heart failure. 1
• Respiratory system: respiratory distress, abnormal breath sounds. 1

Mental Status Examination

Document systematically across all domains: 3

• Appearance and general behavior 3
• Motor activity 3
• Speech (fluency and articulation) 3
• Mood and affect 3
• Thought process (logical, tangential, circumstantial, etc.) 3
• Thought content 3
• Perceptual disturbances 3
• Sensorium and cognition 3
• Insight and judgment 3

Laboratory and Radiographic Testing

Routine laboratory testing and brain imaging have extremely low yield (1.1%) and should NOT be performed routinely. 1

Testing Algorithm:

For clinically stable patients with normal vital signs, appropriate cognition, and noncontributory history and physical examination: no routine laboratory or radiographic testing is needed. 2, 1

Indications for Targeted Testing:

Order tests ONLY when indicated by history and physical examination findings: 1

• Altered mental status 1
• Unexplained vital sign abnormalities 1
• New-onset or acute changes in psychiatric symptoms 1
• Abnormal neurologic findings on examination 1

Tests to Avoid Routinely:

• Routine urine toxicology screens (low yield) 1
• Routine brain CT scans (low yield, unnecessary radiation exposure) 1
• Routine laboratory panels (costly, low yield, increases false-positive results) 1

Risk Assessment

Current Risk Evaluation:

• Current suicidal ideas, plans, and attempts 3
• Current aggressive or psychotic ideas 3
• Documented estimate of suicide risk with influencing factors 3

Safety Planning:

For patients with suicidal ideation, use safety planning rather than no-suicide contracts. 3

Aggression Management:

For patients with aggression, conduct specific assessment of triggers and response to interventions. 3

Documentation Requirements

• All sections clearly documented with date and time 3
• Authentication by the evaluating clinician 3
• Diagnostic formulation based on comprehensive assessment 3
• Treatment plan with rationale 3
• Patient's treatment preferences 3
• Disposition plan (level of care determination) 3

Common Pitfalls to Avoid

• Over-reliance on laboratory testing: History and physical examination are far superior (15.6% and 14.9% yield respectively) for detecting clinically significant conditions. 1
• Ordering "routine" test batteries: This is costly, low-yield, and increases false-positive results. 1
• Failing to obtain collateral information: Patients frequently minimize symptoms or lack insight. 1
• Inadequate attention to vital signs: These are critical predictors of medical pathology. 1
• Neglecting the physical examination: It has a 14.9% yield for detecting conditions requiring management changes. 1
• Neglecting cultural factors: This can lead to misdiagnosis. 4
• Incomplete documentation: Omitting required domains may result in incomplete evaluation. 4