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History Taking in Psychiatry Identification Data Name Age Marital Status/ Occupation Address Ethnic Religion Status (in/

out patient) Reliability Chief Complain Withdrawn for 6 months Hearing voices for 1 month HOPI Characteristics Duration/ date of onset Mode of onset (acute/ chronic) Severity Precipitating factors Aggravating/ alleviating factor Accompanying physiological/ psychological symptom Severity, effects to lifestyles Support (family, friend, relatives) Associated Biological Symptoms Sleep Appetite Weight gain/ loss Energy History of (Direct questioning) Fever Fits Visual disturbances Vomiting Headache Past Medical/ Surgical History Admission Diagnoses Medication/ treatment Outcome Precipitants Past Psychiatric History (Previous illness) Diagnoses Precipitants Admissions Medication/ treatment/ compliance How well between admission Format st Begin with 1 onset of symptoms Progress chronologically to current episode Family History Family tree Family personality Family history of medical/ psychiatric illness Relationship with patients Effect from family members, vice versa Personal History Early Childhood (through age 3) Middle Childhood (ages 3 11) Prenatal, birth history Friends Developmental milestone School Intrafamilial relationships Abnormal Behaviour, Habits (Presence of emotional/ functional disorder) Sleep problems Soiling, bed wetting Stammering, nail-biting Tantrum (sudden aggressive behaviours) Personal History (cont.) Adolescence Puberty Psychosexual history y Menstrual problems y Attitude towards opposite sex y Sexual experiences y Masturbation y Fantasies Dating, peer relations School performance Drug, alcohol use Social History Present social situations y Accommodation y Financial status y Leisure y Social relationship Habits, abuse of drugs Premorbid Personality Relationship Use of leisure Intellectual activities Predominant mood Character Attitude toward work, responsibility Interpersonal relationship Moral, religious standard Energy, initiative Habits Early Adulthood Marital, adult relation Work history Recreational pursuits Middle, Older Adulthood Family constellation Retirement Losses Aging

Mental Status Examination in Psychiatry Appearance & Behaviour Consciousness (overall level) Appearance, state of health Bodily proportion, posture Dress, self care Facial expressions, characteristics Social behaviour, rapport Appropriateness of manner Abnormal behaviour, motor activity Example Thinking Stream/ flow Poverty, inhibition of thought (slowed down) Pressure of thought (compelled to think) Thought blocking Form Flight of ideas Circumstantiality Incoherence Looseness of association, derailment Possession Thought insertion Thought withdrawal Thought broadcasting Content Nature/ content of thought Delusions Overvalued idea Obsessive, compulsive phenomena Phobia Depersonalisation, derealisation Formal Thought Disorders (Definitions) Circumstantiality Overinclusion of trivial, irrelevant details that impede the sense of getting to the point Clang association Thoughts are associated by the sound of words rather than their meaning (through rhyming, assonance) Derailment Breakdown in both logical connection between ideas, overall sense of goal directedness. Words make sentences, but sentences don t make sense Flight of ideas Succession of multiple associations, so that thought seems to move abruptly from idea to idea. Often in rapid, pressured speech Neologisms Invention of new words, phrases, use of concential words in idiosyncratic ways Perseverance Repetition out of context of words, phrases, ideas Tangentiality In response to question, gives a reply that is appropriate to general topic without actually answering the question Thought blocking Sudden disruption of thought, break in flow of ideas Cognitive Function Orientation Time Place Person Attention, Concentration Attention Ability to focus on matter in hand Digit span test

Speech Language Pattern Spontaneity Comprehendible Quantity Rate Reaction time Tone (normal/ monotonous) Emotional Expression Mood (subjective) Affect (objective) What is your mood like? Emotion at time of interview Affect Nature y Depressed y Irritable y Fearful Appropriateness Range y Broad y Restricted Depth y Normal y Blunted y Flat Lability y Quick changes of emotion y Sudden unexpected emotional outbursts Perceptual Disturbances Look for hallucinations, illusions Describe type, content, sensory system involved Content of hallucination Derogatory Praise Reaction (attitude) towards hallucination Happy Sad Angry Confuse Terrified Perplexed Doesn t care

Concentration Ability to sustain that focus 100-7, 40-3, 20-1 Day of week, months backwards Spell WORLD backward

Record time taken, no. of mistakes made Memory Immediate/ Short term/ Recent Registration Digits forward, 5 minutes backward y Address y 5 Unrelated items y Short story Past few days events y Breakfast y Lunch y Dinner Information, Intelligence Comprehension General knowledge Arithmetic, calculations Vocabulary

Remote Long term y Personal events y Birthdate y IC numbers

Abstract Reasoning Similarity, difference testing Proverb Judgement Social Test Personal Insight (Awareness of one s own illness) Is the patient aware of phenomena that others have observed? (eg. he appear to be unusually talkative) Does he recognize that these phenomena as abnormal? Does he consider that they are caused by mental illness? Does he think that he needs treatment?

Formulation, Discussion Summary Demographic details (eg. 23 y/o Malay man, single, unemployed, from KB) Presented with Characterized by Mental status examination revealed Physical examination revealed Diagnosis Provisional Differential Diagnosis Aetiology (Factors) Predisposing Precipitating Perpetuating From early life that Events occur shortly Prolong the course of determine a person s before the onset of a a disorder after it has disorder, appear to been provoked vulnerability to causes (acting close to time of induce it illness)