**Welcome to Psychological Medicine Block(21/11/10-16/12/10)Coordinator: Dr Wee Kok Wei

**Time tableObjectives PSYCHOLOGICAL MEDICINE BLOCK 09/10.doc

E-learning Website: http://www.medlearn.kk.usm.my/To register, please contact the Medical Informatics Laboratory for further information.Login into the system (enter username and password that you have created in step 2).Click on category =phase 2 MD programme Click on the title (psychological medicine)

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Clinical teaching programme:Video shows & Case conferences

students are encourage to practice clerking patients in ward 5U and 5S

**Introduction to History taking and Mental Status Examination In Psychiatry

By: Dr Wee Kok Wei

Psychological Medicine Block Phase II2010

**Psychiatric interviewingThree core function of the interaction between doctor & patient:

1. Gathering data to understand the patient2. Development of rapport and responding to the patient,s emotion3. Patient education and behavioural management(Julian Bird and Steven Cohen-Cole)

**History taking

**IDENTIFICATION DATA Name AgeMarital status/ occupation Address EthnicReligionStatus (in/out patient)Reliability

**PRESENTING COMPLAINTSWhy the patient come to the psychiatrist/ hospitalChief complaintsCC:1) Withdrawn for 6 months 2) Hearing voices for 1 months

**In HOPI:AIMSDevelop differential and provisional diagnosesFind out the precipitating and maintaining factorsAssess severity and complication of the illnessRule out various diagnostic possibilities

**HISTORY OF PRESENTING ILLNESSWhat are the symptoms?How did it all begin?Characteristics Duration / date of onsetMode of onset (acute / chronic)SeverityPrecipitating factors

**Aggravating / alleviating factorAccompanying physiological /psychological symptomSeverity and effects to lifestylesSupport (family / friend / relatives)

**To exclude differential diagnoses:ie TRO Mood DisordersHistory of sustained period of depression or elationAssociated biological symptomsSleepAppetiteWeight gain / lossEnergy

**On direct questioning:History ofFeverFitsVisual disturbancesVomitingHeadache

**PAST MEDICAL / SUGICAL HISTORYHistory ofAdmissionDiagnosesMedication / treatmentOutcomePrecipitants

**PAST PSYCHIATRIC HISTORY Previous illnessDiagnosesPrecipitants AdmissionsMedication / treatment/complianceHow well the patient in between admissionThe history should begin with the first onset of symptoms and progress chronologically to the current episode.

**FAMILY HISTORYFamily treeFamily PersonalityFamily history of medical or psychiatric illnessRelationship with patientsEffect from the family members and vice versa

**Example of Family treeZ12Mother 48 y

**PERSONAL HISTORYA. Early childhood (through age 3)Prenatal and birth historyDevelopmental milestoneIntrafamilial relationships

B. Middle childhood (ages 3 to 11)1. Friends2. School

Abnormal behavior and habits(presence of emotional / functional disorder)Sleep problemsSoiling and bed wettingStammering/nail-bitingTantrum (sudden aggressive behaviors)

**PERSONAL HISTORY ctd..C. Adolescence1. PubertyPsychosexual history Menstrual problems, attitude towards opposite sex, sexual experiences, masturbation and fantasies3. Dating and peer relationships4. School performance5. Drug and alcohol use

**PERSONAL HISTORY ctd..D. Early adulthoodMarital and other adult relationshipsWork historyRecreational and vocational pursuits

**PERSONAL HISTORY ctd..E. Middle and older adulthood1. Changing family constellation2. Retirement3. Losses4. Aging

** Present social situationsAccommodation Financial statusLeisureSocial relationshipHabits / abuse of drugsSOCIAL HISTORY

**PREMORBID PERSONALITYAim at forming a picture of the individual and not the type of individualJudged by asking patient, relatives and observing his behaviour at interviewInclude several important areas including RelationshipUse of leisureIntellectual activitiesPredominant mood

**CharacterAttitude toward work and responsibilityInterpersonal relationshipMoral and religious standardEnergy and initiative Habits

**MENTAL STATUS EXAMINATION

**APPEARANCE AND BEHAVIOR

Overall level of consciousnessAppearance and state of healthBodily proportion and postureDress and self careFacial expressions and characteristicsSocial behavior & RapportAppropriateness of manner Abnormal behavior or motor activity

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The patient is a muscular young man appearing his stated age, wearing jeans, a white t-shirt, and sneakers. He wears several rings on his fingers and bracelets on both wrists. There is an obvious healing cut on his upper lip, which is slightly swollen. He is unshaven, but has an overall neat appearance and adequate hygiene. He sits with his arms crossed in a chair that swivels and uses his feet to swivel through roughly 90 degrees back and forth throughout the interview. He maintains good eye contact.eg;

**SPEECHLanguagePatternSpontaneityComprehendible

QuantityRateReaction timeTone (normal / monotonous)

**EMOTIONAL EXPRESSIONMood (subjective) What is your mood like?

Affect (objective)Emotion at the time of interview

**AffectNatureDepressedIrritableFearfulAppropriatenessRangeBroadRestrictedDepthNormalBlunted Flat LabilityQuick changes of emotionSudden unexpected emotional outbursts

**PERCEPTUAL DISTURBANCESLook for hallucinations or illusionsDescribe the type, content and sensory system involved

Content of hallucination (derogatory,praise and etc)Patients reaction or attitude to the hallucination (happy/sad/angry/confuse/terrified / perplexed / doesnt care

**THINKINGStream /flowPoverty /inhibition of thought (slowed down)Pressure of thought (compelled to think)Thought blockingFormFlight of ideasCircumstantiality IncoherenceLooseness of association / derailment

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**Possession ObsessionsThought insertionThought withdrawalThought broadcastingContent: nature /content of thoughtDelusions Overvalued ideaObsessive and compulsive phenomenaPhobiaDepersonalisation / derealisation

**COGNITIVE FUNCTIONOrientationTime/place/personAttention / ConcentrationAttention is the ability to focus on the matter in hand.>> (digit span test)Concentration is the ability to sustain that focus100 7 ; 40 - 3 ; 20 - 1Day of the week /months of the year backwardsSpell WORLD backwardRecords the time taken and no.of mistakes made

**Memory1. Immediate/registrationdigits forward and backward2. Short term / Recent5 minutes : address / 5 unrelated items /short storyPast few days events : breakfast, lunch, dinner3. Remotelong term eg: personal events , birthdate, I/C numbers

Record any presence of Confabulation-falsification of memory

**Information and intelligencea)Comprehensionb)General knowledgec)Arithmatics / calculationsd)Vocabulary

**Abstract reasoning Similarity & Difference testingProverb Judgment Social, Test and Personal judgment

**INSIGHTAwareness of ones own illnessIs not simply present or absent, but rather a matter of degree4 questions to asses insight:Is the patient aware of phenomena that other people have observed ( e.g. he appear to be unusually talkative)?If so, does he recognize that these phenomena as abnormal?If so, does he consider that they are caused by mental illness?If he accepts that he is ill, does he think that he needs treatment?

**Dont forget the physical examination

**FORMULATION / DISCUSSIONSummaryDemographic details (eg.23 year old Malay man, single , unemployed,from Kota BharuPresented with ..Characterized by..Mental status examination revealedPhysical examination revealed.

**Diagnosis Provisional and differential diagnoses justificationsAetiology Predisposing factorsoperate from early life that determine a persons vulnerability to causes acting close to the time of the illness Precipitating factorsevents that occur shortly before the onset of a disorder & appear to induce itPerpetuating factorsprolong the course of a disorder after it has been provoked.

**ReferencesOxford textbook of psychiatry, 3rd edition, Gelder et al, chapter 1 & 2Comprehensive textbook of psychiatry, 7th edition, Kaplan & Saddock, Chapter 9Companion to psychiatric studies, 6th edition, Eve G Johnstone et al

AcknowledgmentPpt original version by Dr Rohayah Hussain (04/05)Modified version by Dr Asrenee Ab Razak (06/07)

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