Psychiatric History
Psychiatric History
Psychiatric History
HISTORY
SKILL LAB
NBSS
2007
INTRODUCTION
Greeting
Introduction the examiners self
Put the examiner and Patients at ease
Determine the suffering with Compassion and
Empathy
Establish leadership
Balance the roles
IMPORTANT Build doctor-Patient Rapport first
OUTLINE OF PSYCHIATRIC
HISTORY
Identifying Data
2.
Heteroanamnesa
- Chief complaint
- History of present illness
Onset
Precipitating factors
- The Course of Illness
3. Mental Examination
- Observation
- Autoanamnesa
1.
IDENTIFYNG DATA
Name
Age
Education
Marital Status
Occupation
Address/Residence
Religion
CHIEF COMPLAIN
Brief statement in patients own word or
HISTORY OF PRESENT
ILLNESS
Development of symptoms from the time
5.
6.
7.
NEUROSIS
Chronic or recurrent nonpsychotic
disorder characterized mainly by
anxiety, which is experience mainly by
anxiety, which is experienced or
expressed directly or is altered
through defense mechanism; it
appears as symptoms such as an
Obsession, Compulsion, A Phobia or
sexual Dysfunction.
II. PSIKOSIS
Loss of reality testing and impairment of
mental functioning manifested by
Delusions, Hallucinations, Confusion,
and impaired memory
Severe impairment of social and
Personal functioning characterized by
social withdrawal and inability to perform
the usual household and occupation rule
CONCIOUSNESS
State of awareness
- Disorientation
- Clouding of consciousness
- Stupor
- Delirium
- Coma
- Twilight state
- Confusion
- Drowsiness
ATTENTION
Amount of effort exerted in focusing on
EMOTION
Complex feeling state with physic,
EMOTION Cont
AFFECT
EMOTION Cont
MOOD
OTHER EMOTIONS
ANXIETY
FEAR
AGITATION
TENSION
PANIC
APATHY
AMBIVALENCE
ABREACTION
SHAME
GUILT
IMPULSE CONTROL
INEFFABILITY
ACATHEXIS
DECATHEXIS
MOTOR BEHAVIOR
Aspect of psyche that includes impulses,
THINKING
Goal directed flow of idea, symbols and
THINKING Cont
General Disturbances inform or Process:
THOUGHT incontent
Delusion: false belief, based in correct interence
THOUGHT-incontent
- HYPOCHONDRIA
THOUGHT incontent
- COMPULSION
SPEECH
DISTURBANCE IN SPEECH
APHASIC DISTURBANCE
PERCEPTION
Process of transferring physical
PERCEPTION
Hallucination : false sensory perception
PERCEPTION
Olfactory hallucination
Gustatory hallucination
Tactic/haptic hallucination
Somatic hallucination
Illusion; misperception or
MEMORY
Function by which information stored in
MEMORY DISTURBANCE
Amnesia : anterograde, retrograde.
Paramnesia : dejavu, jamais vu
Hyperamnesia
Repression
Level memory:
-immediate memory, recent, recent pass,
remote
INTELLIGENCE
Mental retardation
Dementia
INSIGHT
Intelectual insight
True insight
Impaired insight
JUDGMENT
SEKIAN
WASSALAMUALAIKUM WR. WB