(Redirected from Psychiatric Examination)
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]
- 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?
- process —> coherent, incoherent?
- content —> delusions?
- 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?)
- general description
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]
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