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After Reviewing the History

After Reviewing the History

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Published by Natasha Hanif

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Published by: Natasha Hanif on Jun 19, 2012
Copyright:Attribution Non-commercial

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06/19/2012

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After reviewing the history, this examination is based on the psychiatrist'sobservations and impressions of the patient. It is the most essential component of the psychiatric examination and therefore requires a thorough understanding of thepatient's psychological life. It has various components and subcomponents that canprovide important information leading to a clear diagnosis.
 
General appearance
o
 
Overall appearance
 
o
 
Gait
o
 
Grooming
o
 
Posture
o
 
Gestures
o
 
Facial expression
o
 
Emotional appearance
 
Anxious
 
Tense
 
Panicky
 
Sad
 
Unhappy
o
 
Voice
 
Faint or loud
 
Hoarse
o
 
Eye contact
 
Motoric Behaviour
o
 
Level of activity
 
Psychomotor agitation or retardation
o
 
Tics or tremours
o
 
Automatisms
o
 
Mannerisms
o
 
Grimacing
o
 
Stereotypes
o
 
Negativism
o
 
Apraxia
 
Attitude
o
 
Irritable
o
 
Aggressive
o
 
Seductive
o
 
Guarded
o
 
Defensive
o
 
Indifferent
o
 
Cooperative
o
 
Sarcastic
 
Mood (should be in patient's own words)
o
 
Gloomy
o
 
Tense
 
o
 
Hopeless
o
 
Ecstatic
o
 
Resentful
o
 
Happy
 
Affect
o
 
Labile
o
 
Blunted
o
 
Constricted
o
 
Flat
o
 
Mood congruity and appropriateness
o
 
Range and intensity
 
Speech
o
 
Rate
 
Slow or fast
 
Pressured
 
Interruptable
o
 
Spontaneous
 
o
 
Stammering
o
 
Stuttering
o
 
Slurring
o
 
Pitch
o
 
Articulation
o
 
Aphasia
o
 
Echolalia
o
 
Incoherent
o
 
Mute
 
Perceptual Disorders
o
 
Hallucinations
 
Olfactory
 
Auditory
 
Tactile
 
Gustatory
 
Visual
o
 
Illusions
o
 
Hypnopompic or hypnagogic experiences
o
 
Feelings of unreality
o
 
Deja vu
 
Thought Process
o
 
Logical
o
 
Goal directed
o
 
Loosening of associations
o
 
Flight of ideas
o
 
Tangential
o
 
Relevant
 
o
 
Circumstantial
o
 
Rambling
o
 
Clang association
o
 
Perseveration
 
Thought Content
o
 
Suicidal or homicidal ideation
o
 
Delusions
 
Persecution
 
Grandiose
 
Infidelity
 
Somatic
 
Sensory
o
 
Thought broadcasting or insertion
o
 
Ideas of reference
o
 
Phobias
o
 
Obsessions
o
 
Compulsions
 
o
 
Thought blocking
o
 
Depersonalization
o
 
Magical thinking
 
Sensorium
o
 
Level of consciousness
 
Alert
 
Clear
 
Confused
 
Clouded
 
Comatose
 
Stuporous
o
 
Orientation to person, place, time, situation
o
 
Cognition
 
Memory
o
 
Remote
o
 
Recent
o
 
Immediate
 
Concentration and Calculations
o
 
Ability to pay attention
 
o
 
Distractibility
 
Information and Intelligence
o
 
Use of vocabulary
o
 
Level of education
o
 
Fund of knowledge
 
Judgement
o
 
Ability to understand facts
o
 
Draw conclusions

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