Health Assessment Management (1) & (2)

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The components of a mental health assessment include:

  • History
  • Mental state examination
  • Physical examination
  • Informant history
  • Review of previous notes
  • Investigations
  • Risk assessment

History

  • Record key information
    • Personal information (name, date of birth etc), name and contact details of guardians, source of referral, who else was present. See Other Resources (Part 7) for an example of a good (brief) health passport entry.
  • Presenting problem
    • Ask an open question and record what the person says in his or her own words.
  • History of presenting problem
    • This is usually the MOST IMPORTANT part of the assessment.
      • What symptoms (thoughts / feelings / behaviour) did the person experience?
      • When exactly did this start?
      • Was there a triggering event?
      • Was there a physical illness?
      • Was it linked to alcohol or drug use?
      • What happened next?
      • Have the symptoms changed or worsened?
      • How are the person’s daily activities / work / family life affected?
      • Are there other associated symptoms e.g. changes in sleep, appetite etc?
      • What does the person think is the cause of the problem?
      • Did the person seek treatment previously e.g. medical, traditional healing, prayers? Did it work?
  • Past psychiatric history
    • Past mental illnesses, triggers, symptoms, diagnoses, treatments. Any history of aggression to others or harm to self. Any mental hospital admissions (voluntary/involuntary). Was there full recovery between each episode?
  • Past medical/surgical history
    • Any serious medical illnesses or surgical operations (and dates if recent).
  • Social history
    • Describe current accommodation, occupation, financial situation and family. Who does the patient live with? Is there any current experience of violence or other abuse?
  • Drug history and allergies
    • All current medications, then record all previous psychotropic medications, their dosage and duration and their effectiveness.
  • Family history
    • Family psychiatric illness history (‘breakdowns’), suicides, hospitalisations, drug and/or alcohol abuse.
  • Personal history
    • Find out if there are unusual features of the patient’s early life, development, education, occupational history and relationships.
  • Substance use
    • Alcohol, drug and tobacco use
  • Forensic history
    • Any arrests, any convictions, any violence? Any imprisonments?
  • Premorbid personality
    • How would the patient’s friends/family describe him or her? How does the patient usually cope at times of stress?

Recognise and Rule Out Delirium

When you are taking the history, you might observe:

  • the person is drowsy, disorientated and unable to concentrate
  • there was rapid onset of symptoms
  • there is a history of recent physical illness or ingestion of alcohol/drugs
  • the person is malnourished or dehydrated

If so, check for these features:

  • Is the patient’s level of consciousness reduced? Is he or she less alert and aware of what’s going on than you would expect?
  • Does the patient not know where they are or what day it is?

If these features are present, delirium is likely, so go directly to a physical examination. Delirium is a medical emergency. See Delirium chapter in Part 4.

Mental State Examination

Mental State Examination (MSE)

This is the process of observing the person during the assessment and identifying any abnormal behaviours, thoughts and emotions. You should start to do this as soon as you meet the person, and continue throughout the assessment, noting down anything important. Mental state examination (MSE) can be divided into the following sections:

Appearance and behaviour - what do you notice about the person appearance? What does the person do during the interview? Is the person fully awake or drowsy?

  • Note: general health, hygiene, dress, rapport, eye contact, motor activity (agitation or retardation), abnormal movements (any side-effects from antipsychotics?)

Speech - is there anything unusual about the way that the person speaks?

  • Note: tone, speed, volume. Any made up words?

Mood and affect - what emotions does the person appear to be experiencing?

  • Note: mood is the underlying emotion. Report patient’s own words (subjective) and what you perceive (objective) i.e. low / normal / elated’.
  • Note: affect is the observed (transient) manifestation of the emotion e.g. blunted (lacking normal responses), labile (excessively changeable), irritable (may occur in mania).

Thought content and form - are you able to understand what the person is saying? What are the main things that the person is concerned about? Do they have any unusual beliefs?

  • Note: thought content includes any delusions (fixed, false beliefs, not keeping with patient’s culture), depressed cognitions (e.g. guilt, hopelessness), ruminations (persistent disabling worries), obsessions, phobias. Always ask about suicidal or homicidal thoughts.
  • Note: normal thought form is when statements are connected by their meanings. If it’s very difficult to follow a patient’s thought flow, it’s likely abnormal.

Perception - is the person reporting that they are hearing or seeing anything strange?

  • Note: Illusions are misinterpretations of normal perceptions e.g. thinking a bit of dirt is a small insect – these can happen normally and when tired or physically ill. Hallucinations are perceptions in the absence of an external stimulus e.g. hearing voices (auditory hallucinations).

Cognition - Does the person know where they are (orientation)? Do they have any difficulties remembering things?

Insight - What does the person think explains what is happening? Does the person think that they are ill?

How do I ask questions?

You may be unsure as to how exactly to ask the questions to take the history and, in particular, to ask about specific symptoms such as low mood, suicidal thoughts, and psychotic symptoms. Don’t worry! At the back of this guide you will find examples of questions you can use in both English and Chichewa. You might decide to ask things slightly differently and you should not just go through the questions in a list. However, you will find them helpful to refer to as you learn to conduct psychiatric interviews.

Physical Examination

An appropriate physical examination is an ESSENTIAL part of a psychiatric assessment to rule out physical illness as the cause of a person’s mental health problem, to identify any comorbid conditions, and to assess for effects of self-neglect.

At a minimum you should check vital signs (Heart Rate, Respiratory Rate, Temperature, Blood Pressure) and act on any abnormal findings.

Informant History

Taking a history from people who know the person with the presenting problem is often very helpful. You need to have the permission of the patient to speak to other people unless the person’s judgement and ability to understand the situation is impaired, and/or it is a high risk situation.

Review of Previous Notes

These can provide a lot of very useful information but always make decisions based on your current assessment (as past notes may not always be accurate)

Investigations

Further physical investigations, if available, can help identify underlying medical/surgical causes of delirium and assess the physical state of a person who has not been eating/drinking.