Psychiatric History and Examination Approach

by admin on April 28, 2010

 How to take excellent history in psychaitric patients?

1. Name of patient or gardian/relative (who is giving the history)
2. Relation to the patient
3. Address
4. Permanent Address

5. Name of patient (Block Letters)
6. Present Address.
7. Date of Birth
8. Approx Age:
9. Sex
10. Education: may be illeterate, literate (read and write), primary (upto 5th), middle (upto 8th), upto 10 & 12, Graduation, PG/Technical/professional
11. Occupation
12. When Last Employed:
13. Income:
14. Dependent:
15. Nationality:
16. Mother Tongue:
17. Religion:
18. Marital Status: Unmarried/ Married/ Widow/ Divorced/ Broken Relationship/ Seperated:
19. Numbers of Childer: male and females
20. Living Arrangements: Nuclear family/ joint family/ alone/  any other etc.
21. Reason for consultation:
22. Source of referral:
23. Any previous consultation: from medicine OPD, surgery OPD or any other physician or any psychiatric clinic or hospital

          You should also try to find out whether patient is having addiction to some drugs by asking following questions

1. Age:
2. sex: male or female or eunuch
3. Employment status: following points come under it like, never employed, self employed, presently unemployed, full time employed, part time
employed, student, housewife or girl, any other.

4. Marital status: all of above points you can add whether he was seperated due to drug abuse

5. Substance of abuse like taking alcohol, herion (smack, brown sugar), opium (opium, doda), other opiods like (morphin, proxyvon, parvon forte, parvon plus, parvon, parvon-n, spasmoproxyvon, fortwin etc), cannabinoids (ganja, charas), (sedatives like valium, nitravel, tablet no-10), cocaine,amphetamines,
6. hallucinogens (LSD, PCP), tobacco, or any other.

7. You should also ask have you ever used any injecting drug use, what was the route of administration, sharing of injection or syringe,  what was the name of injectable compound.

8. Have you ever had these sumptoms like, Genital Ulcer Growth, urethral discharge, vaginal discharge, burning micturation, itching around genitals
 retal pain or discharge.

9. Ever had jaundice

10. Ever had sex with sex workers.
11. Ever had HIV screening what was result positive or negative
12. concurrent psychiatric illness
13. concurrent medical illness
14. previous treatment for drug abuse, if nay
15. Ever hospitalized for treatment of drug abuse.

After that you need to take alcohol history, just 10 points you can read here on how to take alcohol history?

                                                          History of Present Illness
onset, duration, progress of each complaints
precipitating factors
late night insomnia, early morning insomnia, midnight disturbance, or normal
Appetite normal or increased or decreased.
Does he or she takes care or hygiene?
Does he or she wearing according to season?
Effect on work increase or decreased or no effect?
Effect on social activities, no effect or increased or decreased.

                      History of past illness and response to treatment
Drug history
Any comorbid illness, any treatment received
Drugs/alcohol what how much, since when.
Any suicidal attempt.
Mental retardation
Family history or mental illness, epilepsy, alcoholism, mental deficienct in family, personality of parents and other members
                                               PEDIGREE DRAWING

You should know how to draw the pedigree of patient

Personal History: premorbid personality, education, occupational, sexual, menustral, marital habits, special aptitudes.

Do the examinations of all systems.

                                                                Psychiatric Examination
1. General Appearance and behaviour:
2. Personal Hygiene:
3. Psychomotor Activity:
4. Eye Contact: whether making or not
5. Appearance like tideness, facial expression, abnormality of behviour, negativism, mannerism, stereotype, muttering, casusless, laughter
, restlessness, compulsive sets, level of consciousness (clouding-Delirium-Stupor-Coma)
6. Attention and concentration: whether focused or sustained.
7. Preoccupied Fleeting
8. Speech– a) see the form like stammering, mute, absurd answers
 b) see the flow of speech, overtalkativeness, flight of ideas, circumstantiality-clabng association, rhyming,
preservation, retarted, block, mutism, laconic answers
 c)see the content of speech like irrelevant, incoherent and stereotype.
9. Thinking- like idea of reference, control, passivity feelings, depersonalisation, derealisation, obsessive idea, thought block, delusion,
phobia
10. Illusion and hallucinations
11. Emotions like apathy, depression elation, incongruity anxiety, ambivalence, indifference and apprehension.
12. whether person is oriented to time place and person or not.
13. see his memory (recent, remote, confabulations)
14. Intelligence and judgement- see dementia deficiency.
15. see insight whether partial or lacking

This much is sufficient for making diagnosis in psychiatry.

For Further Reading :

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