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Examination Of A Psychiatric Patient: The Health Significance Of Taking A Patient History

Updated on February 20, 2014

Doctor And A Psychiatric Patient

Source

A General Overview

Examination of a psychiatric patient is in general similar to that of a medical case. The first part consists of history taking and the next part consists of a mental examination. In addition, a full physical examination is required for all cases. An informant to whom the patient is closely known should be selected for eliciting the history, especially in the case of psychosis and mental retardation. A scheme followed in psychiatric examination is given below.

History

  1. Bio- data
  2. History of the present illness
  3. Family history
  4. Premorbid personality
  5. Presenting complaints
  6. History of past illnesses
  7. Personality history
  8. Personal habits including addiction

Mental status examination

  1. Appearance and behavious
  2. Psychomotor activity
  3. Affect
  4. Thinking
  5. Perception
  6. Consciousness
  7. Orientation
  8. Attention and concentration
  9. Memory
  10. Intelligence
  11. Judgement
  12. Insight

Physical Examination

  1. General
  2. Systemic

Provisional Diagnosis

Others…

A Psychiatric Pateint

Source

Taking The History

Bio-data: The name, address, age, sex, income, education, occupation and marital status are noted.

Presenting Complaints: The common presenting complaints include aggression, violence, excessive talk, retarded motor activity, suicidal behaviour, insomnia, loss of appetite, body aches and pains, paralysis, loss of memory, poor intelligence, habituation to drugs and intoxicants and sexual disorders. The presenting complaints are recorded in sequential order.

History or present illness: All details of the illness from its onset to the present state should be vividly described. Details of treatment have to be recorded. Leading questions may be required to bring out features such as suicidal tendencies, obsessions, delusions or hallucinations.

History of past illness: This should include all psychiatric problems, medical illnesses, physical trauma and accidents. Important events from birth (including birth injuries) and milestones of development have to be obtained.

Family history: All details of the family members, their interrelationship, the family structure, the attitude of other family members towards the patient and occurrence of psychiatric illnesses in family members have to be elicited. It is always desirable to construct a family tree.

Personal history: All details regarding occupation, work, socio-economic status, sexual activity, addictions, marriage and marital adjustments and details of the children should be recorded.

Premorbid personality: This refers to the personality of the individual before developing the illness. This should include the general mental state including his hobbies, likes and dislikes etc.

In Conclusion

This may seem as an awareness only for doctors, or medical personnel actively involved in psychiatry but it is not. Psychiatric conditions tend to attract a lot of talking, questioning and answering questions and most of what the doctor is doing is trying to use this methodology described in this hub to try to find out the cause, root of the mental illness. Sometimes inpatient patients are encountered, and surprisingly, even the relatives of some patients become so inpatient. All the psychiatrics is doing is trying to help and without details such as these, he cannot get to the root of the problem. The procedure do not just stop here as our next hub will take us to the mental status examinations observed when examining a patient. Just click next in the slide under.

© 2014 Funom Theophilus Makama

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    • married2medicine profile imageAUTHOR

      Funom Theophilus Makama 

      4 years ago from Europe

      Thanks a lot lambservant

    • lambservant profile image

      Lori Colbo 

      4 years ago from Pacific Northwest

      Very informative and helpful.

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