Psychiatric examination

Structure of Anamnesis for the credit

Credentials of patients

• Name, date of birth

Reason for admission

• 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

• 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

• (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 therapy (pharmacotherapy, psychotherapy)

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

Example (under construction)

Patient XY

Links

References

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