How to present on psychiatry rounds
A psychiatry presentation sounds different from the rest of the hospital. There is less lab data and more observation, and the mental status exam does the work of the physical exam. Your attending needs the legal status and the safety picture up front, then an MSE precise enough to picture the patient without walking into the room.
- Target
- 3 to 5 minutes on inpatient rounds or a consult
- Lead with
- Legal status, safety, and a precise MSE
Here is the format inpatient teams expect, a word-for-word example from a fictional manic episode, and the questions that come up on the unit.
What your attending listens for
Psychiatry presentations center on legal hold status, the safety assessment (suicidal and homicidal ideation, hallucinations), how the patient behaved on the unit, and a precise mental status exam.
The structure
Step 1: Legal and psychiatric ID line
Age, sex, psychiatric diagnoses, legal status (voluntary, or the day of an involuntary hold), and why the patient was admitted: suicidal ideation, mania, psychosis.
Step 2: Unit events and subjective
Hours of sleep, percent of meals eaten, medication adherence, PRN medications for agitation, group participation, and the patient's own words about mood and goals.
Step 3: Mental status exam
Appearance, behavior and psychomotor activity, speech (rate, volume, tone), mood in the patient's words, affect (range and congruence), thought process, thought content (SI, HI, delusions), perception (hallucinations), insight and judgment.
Step 4: Vitals, labs and drug levels
Vitals, with orthostatics or signs of autonomic instability, urine drug screen, alcohol level, TSH, B12, the QTc on the ECG, and lithium, valproate or clozapine levels.
Step 5: Formulation and risk
The biological, psychological and social factors behind this admission, then the acute and chronic risk of suicide or violence.
Step 6: Three-part plan
Medications (titration and side effect monitoring), therapy and the milieu, and disposition with safety planning.
A word-for-word example
Step 1: Legal and psychiatric ID line
Mr. Jordan is a 26-year-old man with bipolar I disorder, admitted involuntarily and now on day 3 of his hold, for a manic episode with psychotic features after he stopped his medications.
Step 2: Unit events and subjective
Overnight he slept 5 hours, up from 2 on admission. He took all his scheduled medications, needed no PRN haloperidol, and ate all of his meals.
Step 3: Mental status exam
On mental status exam he is casually dressed and mildly restless. Speech is rapid but interruptible, improved from pressured. Mood is "great," and affect is expansive. Thought process is circumstantial, with fading grandiose delusions. He denies suicidal ideation, homicidal ideation and hallucinations. Insight is limited; judgment is improving.
Step 4: Vitals, labs and drug levels
His lithium level this morning is 0.8, creatinine is 0.9, and his QTc is 428.
Step 5: Formulation and risk
This is a 26-year-old man with bipolar I disorder in an acute manic episode, triggered by stopping his medications and responding to lithium and olanzapine. His acute risk on the unit is low.
Step 6: Three-part plan
We will continue lithium 600 milligrams twice daily, which puts him at the low end of the therapeutic range, and olanzapine 15 milligrams at bedtime. He will keep attending groups, and we will hold a family meeting tomorrow before he steps down.
Ward pearls
- Never confuse mood and affect. Mood is subjective, in the patient's words and in quotation marks ("depressed"). Affect is what you observe ("constricted, dysphoric, mood-congruent").
- Always say whether suicidal ideation is passive ("I wish I wouldn't wake up") or active, with intent, a plan, or access to means.
- Check and report the QTc before you start or increase an antipsychotic or citalopram.
- Report sleep hours and meal intake every morning. They are the most objective vital signs in inpatient psychiatry.
Classic pimp questions
- Neuroleptic malignant syndrome versus serotonin syndrome: lead-pipe rigidity versus clonus and hyperreflexia
- The timeline of extrapyramidal symptoms: acute dystonia, akathisia, parkinsonism, tardive dyskinesia
- Clozapine monitoring: the ANC for severe neutropenia, myocarditis, and seizures
- DSM-5 duration criteria: a major depressive episode 2 weeks, mania 1 week, hypomania 4 days, schizophrenia 6 months
Not sure how to field them? How to take the questions
Practice it out loud
A script you have read is not one you can say. Present a fictional patient to an AI attending who cuts in, asks why, and grades you on a rubric, then drills whatever you missed.
Try a free caseOne case, free. No signup, no card.
Other rotations
Educational content with fictional patients, not medical advice. Teams and institutions differ: follow your attending, your institution's protocols and current guidelines.