Psychiatry History Taking and Examination

BySoheir H. ElGhonemy

Assistant Professor of Psychiatry,MD in Psychiatry, Arab Board in Psychiatry

Member of International Society of Addiction Medicine (ISAM)

The psychiatric history is the chronological

story of the patient’s life from birth to present

Personal data:

Name, age, sex, marital status, religion, address, occupation, education.

n.b.; source of referral could be mentioned here if the patient can’t cooperate

Complaint: In the patients own words.Informant complaint; ( reliable informant)

History of the present illness:

Onset, duration of illness, Development of symptoms and relation of

events, stressors, Change from previous level of functioning,

medication taken with the reported response and compliance,

Previous hospitalization and their duration and level of improvement.

Past History: Includes both psychiatric and medical ; neurological illnesses.

Personal History:Developmental history ; prenatal, natal, postnatal.Childhood,Adolescence,Adulthood; work history, marital history, children, level of education, finance, military history…etc.Premorbid personality.Sexual History; sexual development, masturbation, sexual dysfunction.

Family History:

Psychiatric and medical histories.

Name, age, occupation of the family members (father, mother, siblings), order of birth of the patient, and the relationships between the family members as reported by the patients.

Examination

* Mental state examination: ,General appearance; appearance, grooming, gait٭posture, facial expression.,Level of activity; retarded, agitated, tics, tremors٭…etc. Attitude; cooperative, hostile, eye to eye٭contact….etc. ,Level of consciousness; orientation to time, place٭and person, attention and concentration. Memory; immediate, recent, remote٭

Mood:Patient’s expression of his own feeling (subjective description)  Affect:Examiner’s expression of the patient’s feeling and its appropriateness to the situation (objective description).Speech:Description of the patient’s speech; slow, fast, spontaneous, fast, slurred…etc.

* Thought Examination:*Form; off pointing, thought block, tangential, circumstantial, loose association, neologism, incoherence.*Stream; fast, pressure of thoughts, flights…etc.*Content; delusions, obsessions, phobias…etc.*Control; broadcasting, insertion, withdrawal, reading.*Abstraction and judgment.

Perceptual Examination:Illusions; misinterpretation of stimulus.

Hallucination; perception with No stimulus Examine : type (visual, gastatory, olfactory, tactile or auditory), timing, content, frequency and reaction of the patient Insight; for illness, symptoms, need for treatment and compliance.

Good luck