Psychiatric examination

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Structure of Anamnesis for the credit[edit | edit source]

Credentials of patients[edit | edit source]

  • Name, date of birth

Reason for admission[edit | edit source]

  • current problem described by patient, in their words; Important to ask this early as to show interest in patient's problem; can ask collaterals about main issue here too: any other symptoms? what mood? sleeping issues? eating habits? energy levels...?

Medical Anamnesis[edit | edit source]

  • Family (Parent, siblings, children - age, death, relationship with; history of mental diseases)
  • Somatic status and diseases (Any current comorbidities?)
  • Allergies, medications taken
  • Substance abuse (Alcohol, smoking, elicit drugs)
  • Past life (Key events [traumatic or otherwise important], relationships with family members/friends/partners)
  • Social status (living conditions: alone or with someone? financial status?
  • Work: profession? how many jobs has the patient changed? highest level of education achieved
  • Sexual life: how many partners in past and present?
  • If female: Gynacological anamnesis [mensis, menopause, pregnancies/deliveries/abortions, surgeries, contraceptives]
  • if time permits: Hobbies, interests? - can give us insight into patient's status
  • Self concept: describe yourself to me... [macromania? micromania? both are delusions]
  • Wishes: what do you wish for? Can elaborate on person’s thinking, plans, etc.

Psychiatric anamnesis[edit | edit source]

  • (hospitalization history, suicidal attempts; outpatient psychiatrist). From psychiatric anamnesis we mainly want to gain patient's current mental state; describe the mental state of patient seen TODAY [subject to change]:
    • general description
      • conscioussnes: vigilant? lucid?
      • orientation: delerious? In contact with reality?
      • Psychomotoric tempo [evaluate speech and movements!]: slow can indicate depression or catatonia; fast can indicate mania or anxiety]
      • appearance
      • Answer coherence: the question answered - without delay? With delay? [delay in answering can indicate depression, dementia or hallucinations (waiting for voices' instructions before answering)]
      • Intoxication status (describe and signs of withdrawal, if apparent)
    • mood [sad, elevated, normal], affect = emotional reactivity [calm/stable, instable/irritable, Impulsive]; anxiety level? tension?
    • Thinking:
      • process —> coherent, incoherent?
      • content —> delusions?
    • Hallucinations?
    • Suicidal ideation (just thoughts)? tendencies (thoughts materializing into actions)?
    • aggression (auto and hetero! can be verbal, toward things or brachial aggression)
      • NB: suicidal ideation/tendencies and presence of aggression will determine if patient will be hospitalized involuntary!!!
    • Self harming
    • Insight - none? present? (full or partial?)

Write proposed diagnosis[edit | edit source]

Write DDx[edit | edit source]

Write proposed therapy (pharmacotherapy, psychotherapy)[edit | edit source]

NB: Whatever you do, if you no time - must acquire at least: comorbidities, present allergies and drugs taken (chronic, intoxication).

Example (under construction)[edit | edit source]

Patient XY

Links[edit | edit source]

Related Articles[edit | edit source]

Bibliography[edit | edit source]

References[edit | edit source]

  • Structure as proposed by MUDr. Podgorná, Psychiatrist at 1.LF UK- summarized by Betty Berezovsky