RxPG - Psychiatry Clinical Examination Format with Examples

Psychiatric Clinical Examination

Basic Information

Name, Age, Sex, Occupation, Address

Identification Marks – Medico legal purpose

Informant à to be reliable (who is staying with patient during the illness)

Chief Complaints (as patient and relative say)

General

- Sleep Disturbances, Appetite, Appearance, Sex, Personal Relationship, Day to Day Activity, Behaviour.

Schizophrenia

- Talking to Self, Laughing to Self, Hearing Voices, Suspicious about Others, Not doing any job, Lack of Personal Care, Violent behavior, Suicidal Attempt, Somebody trying to kill him, Somebody watching him.

Depression

Reduced Activity, Not talking with Others, Crying Spells, Death Wish, Guilty Feeling, Worried about Future Life.

Mania

- Excessive Talk, increased Activity, Frequently Changing the Dress, Dressed Neatly, Talk about Superior power, Talk of Wealthiness, Talking that she is the God.

Delusional disorders

- Suspicious about Wife or Husband
- Crawling sensation over the head or body

Psychotic Symptoms

- Hearing Voices, Suspicious about Others

Neurotic Symptoms

- Headache, vomiting, palpitation, Chest pain, Fear of Death, Fear of having some Illness, Fear to go to Crowded Place, Fear to Stay Alone, Fear to stay in Height Place, Repeated checking, Repeated washing, Repeated thought, multiple pain site.
Hysterical Symptoms

- Sudden fainting attack, H/O jerky movements for long time., Mute

History of Present Illness

- Onset - Sudden, gradual
- Precipitating Factors
- Course – Episodic, Progressive

H/O Previous Illness

- Past Psychiatric Consultation
- Past Medical History

Family History

- Pedigree Chart
-
- Male Female

à Mental Illness

Died

- Family Background
- Parents and Siblings
- Family History of Mental Illness

Personal Life History

A. Early Childhood

1. Developmental Mile Stones
2. Intrafamilial Relationship

B. Middle Childhood

1. Friends
2. School

C. Adolescence

1. Puberty
2. Psychosexual History
3. Dating & Peer Relationship
4. School Performance
5. Drug & Alcohol abuse

D. Early Adulthood

1. Marital and Other Adult Relationship
2. Work History
3. Recreational & Vocational pursuits
4. military History
5. Prison History

E. Middle and Old Adulthood

1. Changing Family constellation
2. Retirement
3. Loses
4. Aging

- Birth, Childhood, Education Occupation, Marriage, Sexual Practice, Mental History (Female), Habits liked Alcohol, Drugs & Smoking, Religious Practices, Hobbies, Interests, Daily Activity)

Pre morbid Personality

- Reserved (Introvert)
- Social (Extrovert)
- Suspicious (Paranoid)
- Perfectionist (Obsessive)
- Hysterical
- Antisocial
- Aggressive
- Frequent Mood Change (Cyclothymics)

Mental Status Examination

General Appearance & Behaviour

- dressing, Care of Hair, Care of Nail
- Personal Hygiene
- Psycho Motor Activity
- Touch of Surrounding or Not
- Rapport

Speech

- Tone & Quantum of Speech
- Relevant / Irrelevant
- Coherent /incoherent
- Neologism

Mood & Emotional State

- Affect – Reacting or Not
- Subjective Mood
- Objective Mood

- Depressed, Irritate, Elated, Agitated, labile Mood

Thought Form & Context

Thought form

- Circumstantialities
- Derailment
- Flight of Ideas
- Neologism
- Thought Block

Thought Context

- Delusions
- Ideas of Reference
- Obsessions
- Preoccupation with Suicidal Ideas

Perception

- Illusion
- Hallucinations

Higher Functions

1. Alertness
2. Orientation
a. Person
b. Time
c. Place

3. Attention and Concentration
4. Memory
a. Immediate
b. Recent
c. Remote

5. Abstract Thinking
6. Judgment

Insight

- Whether the person knows that he is mentally ill or not and to what extent.