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    Psychiatric Assessment and Evaluation: History Taking

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    Waheedullah Ahmadi
    The document outlines the process for conducting a psychiatric assessment, including collecting information on a patient's biographical details, chief complaints, medical, psychiatric, and family history, and conducting a mental status examination. Key areas of focus include evaluating mood, thought processes, cognition, and assessing risk. Based on the collected information, a diagnosis would be made using ICD-10 criteria and treatment would be developed using a biopsychosocial approach, including biological testing, psychological assessments, social evaluation, and pharmacological treatment.

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    Psychiatric Assessment and Evaluation: History Taking

    Uploaded by

    Waheedullah Ahmadi
    112 views9 pages
    The document outlines the process for conducting a psychiatric assessment, including collecting information on a patient's biographical details, chief complaints, medical, psychiatric, and family history, and conducting a mental status examination. Key areas of focus include evaluating mood, thought processes, cognition, and assessing risk. Based on the collected information, a diagnosis would be made using ICD-10 criteria and treatment would be developed using a biopsychosocial approach, including biological testing, psychological assessments, social evaluation, and pharmacological treatment.

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    The document outlines the process for conducting a psychiatric assessment, including collecting information on a patient's biographical details, chief complaints, medical, psychiatric, and family history, and conducting a mental status examination. Key areas of focus include evaluating mood, thought processes, cognition, and assessing risk. Based on the collected information, a diagnosis would be made using ICD-10 criteria and treatment would be developed using a biopsychosocial approach, including biological testing, psychological assessments, social evaluation, and pharmacological treatment.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    112 views9 pages

    Psychiatric Assessment and Evaluation: History Taking

    Uploaded by

    Waheedullah Ahmadi
    The document outlines the process for conducting a psychiatric assessment, including collecting information on a patient's biographical details, chief complaints, medical, psychiatric, and family history, and conducting a mental status examination. Key areas of focus include evaluating mood, thought processes, cognition, and assessing risk. Based on the collected information, a diagnosis would be made using ICD-10 criteria and treatment would be developed using a biopsychosocial approach, including biological testing, psychological assessments, social evaluation, and pharmacological treatment.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 9

    Balochistan Institute of Psychiatry and Behavior Science

    Psychiatric Assessment and evaluation

    History taking

    1. Bio data.
     Name
     Age
     Sex
     Religion
     Marital status
     Education
     Occupation/Employment
     Address/ Resident
     Brought by

    2. Informant (Reliable/ Not Reliable).

    3. Chief Complaints.

    4. HOPC (History of Present Complication/HOPI (History of Present


    Illness)
     Opening statement

     Elaboration of chief complaints


    a. Duration
    b. Onset
    c. Course/Nature
    d. Aggravating and Reliving factors
    e. Associating symptoms

     Biological symptoms
    1. Sleep
    2. Appetite
    3. Libido
    4. Body ache
    5. Amenorrhea
    6. Fatigue
    7. Weight loose
    8. Constipation

    Dr Rahmatullah Roshan 1
    Balochistan Institute of Psychiatry and Behavior Science

     Functionality
    1. Social
    2. Occupational
    3. Personal
    4. Domains

     Risk Assessment
    1. Suicidal/ Homicidal
    2. Ideas/ Attempts
    3. Rush Driving
    4. Risky Behavior

     Current Medication

     Substance (Habits) History

     Trauma History

     Forensic (Criminals) History

     ECT History

     Depo History

    5. Past History
     Past Psychiatric Illness
    I. OPD Visit/ Treatment Record
    II. Admission/ Hospitalization
    III. Relapse/ Remission ………. Episodic/ Continues
    IV. Complain....... Good/ Poor
    V. Drug Abuse

     Past Medical History


    I. Diabetes
    II. Malaria, Typhoid
    III. Hypertension
    IV. Asthma
    V. Infectious Diseases
    VI. Tuberculosis
    VII. Hepatitis
    VIII. Past Treatment History
    IX. Chronic Illness

    Dr Rahmatullah Roshan 2
    Balochistan Institute of Psychiatry and Behavior Science

     Past Surgical History


     Any Surgical History
     Blood transfusion

    6. Family History
     Parents Alive/ Died ……. Healthy/ ill
     Sibling …… Number of Siblings …….. Number of Among Siblings
     Psychiatric Illness History in Family
     Family Relationship with Patients
     Patient Relationship with Family

    7. Personal History
     Antenatal History…… Illness/ Drug use During Pregnancy
     Natal History
     Birth Place ……. Hospital/ Home
     Mode of Delivery …….. SVD/ CS (C Section)
     Any Problem during Birth ….. Birth Asphaxia/ Prematurity

    8. Postnatal History
     Low Birth Weight
     Illness
     Any fever

    9. Developmental History
     Milestones
     Talk, Speak, Ear, Walk …

    10. Child hood History


     Separation of child from Parents or Separation b/w Parents
     History of Head Trauma
     High grade Fever
     Fits and etc in Childhood

    11. Schooling History


     Education …… Formal/ Informal/ Religious
     Intelligence level …… Dull/ Average/ Intelligent
     Relationship with Teachers and Class Fellows
     Academic Record/ Performance
     Father Education …….. School/ Collage/ University

    12. Psychosexual History


     Age of Puberty/ Menarche

    Dr Rahmatullah Roshan 3
    Balochistan Institute of Psychiatry and Behavior Science

     Secondary Sexual Characteristics (Normal/ Delay)


     First Sexual Experience
     Behavior
     Attitude
     Sexual Preference
     Prevention any instance of sexual Abuse…. Childhood incidents,
    Pornography, safe or unsafe sex, Homo/ Hetro Sexuality

    13. Marital History


     Marriage Age
     Cousin Marriage
     Arrange Marriage/ Love Marriage
     Relationship with Wife
     Relationship with Children

    14. Occupational History


     List of Jobs he did in choulogical order
     Duration of Employment
     Reason of Leaving
     Any Periods of unemployment

    15. Drugs History


     Do you smoke of Drink alcohol or take any drugs which the doctor has not
    prescribed?
     List of Drugs Patient Used
     Their use is regular or not
     If regular, what is pattern of use?
     Quantity and frequency of use
     Any Physical, Psychological or Social impact?

    16. Forensic History


     Have you done any thing that could have got you in trouble with Police?
     List of offences e.g ….. Violent, Social or Sexual Crimes

    17. Pre morbid History


     How would People who know you describe you?
     Attitude to others e.g Friendly, Trusting etc
     Attitude to self e.g Likes self is confident etc
     Pro dominant e.g Cheerful, Optimistic, pessimistic etc
     Leisure Activities and interests e.g Hobbies etc
     Coping strategies in stress
     Fantasies

    Dr Rahmatullah Roshan 4
    Balochistan Institute of Psychiatry and Behavior Science

     Personality Traits …. Obsessional, Paranoid, Schizoid, Dependent,


    Antisocial etc

    Dr Rahmatullah Roshan 5
    Balochistan Institute of Psychiatry and Behavior Science

    Physical Examination

    MSE (Mental State Exam)

     Speech
     Loosing association
     Flight of Idea
     Pressured Speech

     Mood
     Quantity
     Quality
     Diurnal variation
     Social interaction
     Opposite Pole
     Cognitive: Concentration, Memory
     Emotional symptoms: Future Life, Haplessness, Suicidal Ideas
     Copping skills

     Thought
     Delusion of Percussion
     Delusion of Reference
     Delusion of Insertion
     Delusion of Control
     Delusion of Withdrawal
     Delusion of Broadcasting
     Delusion of Grandiosity
     Delusion of Religion
     Delusion of Jealousy
     Delusion of Nehlism
     Delusion of Hypochondriasis
     Delusion of Guilt
     Delusion of Poverty
     Delusion of Obsession

     Perception
     Auditory
     Somatic
     Visual
     Olfactory
     Gustatory

    Dr Rahmatullah Roshan 6
    Balochistan Institute of Psychiatry and Behavior Science

    Mini Mental State Exam (MMSE)

    Cognition:

    1. Ovulation: Time, Place, Person


    2. Attention & Concentration 21-3 / 100-7
    3. Registration & Recall, Give 3 words & ask to repeat.
    4. Abstract: Something is Fishi
    5. Judgment: Five/ Earth quack
    6. Short term memory: Repeat those 3 words
    7. Long term memory: DOB, PM Name
    8. Insight: (Six Levels of Insight are Below)
    I. Complete denial of illness
    II. Slight awareness of being sick & needing help but denying it at the same time.
    III. Awareness of being sick but blaming it on others, on external factors, or on
    organic factors.
    IV. Awareness that illness is due to something unknown in the patient.
    V. Intellectual insight.
    VI. True emotional insight

    Diagnosis:
    According to ICD 10 on
    Axis I:
     Recurrent Depression, Current Episode Severe or Psychotic Feature

    Different Dx:
    i. Organic Anxiety Disorder (Hypothyroid)
    ii. Adjustment Disorder
    iii. Bipolar Anxiety Disorder (BPAD)
    iv. Personality Disorder

    Axis II:
     Functionality impairment

    Axis III:
     Predisposing Factor: + Family History
     Aggravating Factor: Marital Conflict, Financial Issues, Diverse/ Family Stressor
     Maintaining Factor: Poor Compliance of Medicine

    Assessment
     I will admit Patient
     To complete Assessment for convert to Dx Based on Bio – Psycho – Social Model

    Biological Assessment
     CBC
     Urea/Creatinine

    Dr Rahmatullah Roshan 7
    Balochistan Institute of Psychiatry and Behavior Science

     HBsAg
     Anti HCV
     HIV
     ECG
     Thyroid Profile
    Psychological Assessment
     Back Depression Scale
     Hemelton Scale
     YMR ( ) Scale

    Social Assessment
    Collateral History from
     Spouse
     Parents/ Sibling
     Friends

    Treatment
     After complete assessment and development, Dx (Diagnose) will treat my patient
    based on Bio – Psycho – Social – Model.

    Biological Tx (Treatment)
    Pharmacotherapy
    o Anti depressant
    o Anti psychotic
    o Mood stabilizer
    o Short term Benzodiazepine
    o ECT

    Psychological Tx
     Psycho Education (Mature copping skills) and information co regarding Pt
    psychotic illness + Tx.
     Family Therapy: lower high expose emotion (Criticism/ Negativism)
     CBT ------ Thought Impairment and Behavioral Impairment

    Social Treatment
     Financial Support
     Better Social Company
     Job/ Employment offers

    Prognosis
    Short term:
     Good Prognosis
     Self environment
     Close Observation & Care
     Active Treatment

    Dr Rahmatullah Roshan 8
    Balochistan Institute of Psychiatry and Behavior Science

     Family support

    Long term:
     Not Favorable
     Family Hx
     Multiple Episodes and relapse
     Multiple Stresses
     Female Gender
     Poor copping skills
     Multiple Suicidal Attempts

    Dr Rahmatullah Roshan 9

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