Balochistan Institute of Psychiatry and Behavior Science

Psychiatric Assessment and evaluation

History taking

1. Bio data.
 Name
 Age
 Sex
 Religion
 Marital status
 Education
 Occupation/Employment
 Address/ Resident
 Brought by

2. Informant (Reliable/ Not Reliable).

3. Chief Complaints.

4. HOPC (History of Present Complication/HOPI (History of Present

Illness)
 Opening statement

 Elaboration of chief complaints

a. Duration
b. Onset
c. Course/Nature
d. Aggravating and Reliving factors
e. Associating symptoms

 Biological symptoms
1. Sleep
2. Appetite
3. Libido
4. Body ache
5. Amenorrhea
6. Fatigue
7. Weight loose
8. Constipation

Dr Rahmatullah Roshan 1
Balochistan Institute of Psychiatry and Behavior Science

 Functionality
1. Social
2. Occupational
3. Personal
4. Domains

 Risk Assessment
1. Suicidal/ Homicidal
2. Ideas/ Attempts
3. Rush Driving
4. Risky Behavior

 Current Medication

 Substance (Habits) History

 Trauma History

 Forensic (Criminals) History

 ECT History

 Depo History

5. Past History
 Past Psychiatric Illness
I. OPD Visit/ Treatment Record
II. Admission/ Hospitalization
III. Relapse/ Remission ………. Episodic/ Continues
IV. Complain....... Good/ Poor
V. Drug Abuse

 Past Medical History

I. Diabetes
II. Malaria, Typhoid
III. Hypertension
IV. Asthma
V. Infectious Diseases
VI. Tuberculosis
VII. Hepatitis
VIII. Past Treatment History
IX. Chronic Illness

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Balochistan Institute of Psychiatry and Behavior Science

 Past Surgical History

 Any Surgical History
 Blood transfusion

6. Family History
 Parents Alive/ Died ……. Healthy/ ill
 Sibling …… Number of Siblings …….. Number of Among Siblings
 Psychiatric Illness History in Family
 Family Relationship with Patients
 Patient Relationship with Family

7. Personal History
 Antenatal History…… Illness/ Drug use During Pregnancy
 Natal History
 Birth Place ……. Hospital/ Home
 Mode of Delivery …….. SVD/ CS (C Section)
 Any Problem during Birth ….. Birth Asphaxia/ Prematurity

8. Postnatal History
 Low Birth Weight
 Illness
 Any fever

9. Developmental History
 Milestones
 Talk, Speak, Ear, Walk …

10. Child hood History

 Separation of child from Parents or Separation b/w Parents
 History of Head Trauma
 High grade Fever
 Fits and etc in Childhood

11. Schooling History

 Education …… Formal/ Informal/ Religious
 Intelligence level …… Dull/ Average/ Intelligent
 Relationship with Teachers and Class Fellows
 Academic Record/ Performance
 Father Education …….. School/ Collage/ University

12. Psychosexual History

 Age of Puberty/ Menarche

Dr Rahmatullah Roshan 3
Balochistan Institute of Psychiatry and Behavior Science

 Secondary Sexual Characteristics (Normal/ Delay)

 First Sexual Experience
 Behavior
 Attitude
 Sexual Preference
 Prevention any instance of sexual Abuse…. Childhood incidents,
Pornography, safe or unsafe sex, Homo/ Hetro Sexuality

13. Marital History

 Marriage Age
 Cousin Marriage
 Arrange Marriage/ Love Marriage
 Relationship with Wife
 Relationship with Children

14. Occupational History

 List of Jobs he did in choulogical order
 Duration of Employment
 Reason of Leaving
 Any Periods of unemployment

15. Drugs History

 Do you smoke of Drink alcohol or take any drugs which the doctor has not
prescribed?
 List of Drugs Patient Used
 Their use is regular or not
 If regular, what is pattern of use?
 Quantity and frequency of use
 Any Physical, Psychological or Social impact?

16. Forensic History

 Have you done any thing that could have got you in trouble with Police?
 List of offences e.g ….. Violent, Social or Sexual Crimes

17. Pre morbid History

 How would People who know you describe you?
 Attitude to others e.g Friendly, Trusting etc
 Attitude to self e.g Likes self is confident etc
 Pro dominant e.g Cheerful, Optimistic, pessimistic etc
 Leisure Activities and interests e.g Hobbies etc
 Coping strategies in stress
 Fantasies

Dr Rahmatullah Roshan 4
Balochistan Institute of Psychiatry and Behavior Science

 Personality Traits …. Obsessional, Paranoid, Schizoid, Dependent,

Antisocial etc

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Balochistan Institute of Psychiatry and Behavior Science

Physical Examination

MSE (Mental State Exam)

 Speech
 Loosing association
 Flight of Idea
 Pressured Speech

 Mood
 Quantity
 Quality
 Diurnal variation
 Social interaction
 Opposite Pole
 Cognitive: Concentration, Memory
 Emotional symptoms: Future Life, Haplessness, Suicidal Ideas
 Copping skills

 Thought
 Delusion of Percussion
 Delusion of Reference
 Delusion of Insertion
 Delusion of Control
 Delusion of Withdrawal
 Delusion of Broadcasting
 Delusion of Grandiosity
 Delusion of Religion
 Delusion of Jealousy
 Delusion of Nehlism
 Delusion of Hypochondriasis
 Delusion of Guilt
 Delusion of Poverty
 Delusion of Obsession

 Perception
 Auditory
 Somatic
 Visual
 Olfactory
 Gustatory

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Balochistan Institute of Psychiatry and Behavior Science

Mini Mental State Exam (MMSE)

Cognition:

1. Ovulation: Time, Place, Person

2. Attention & Concentration 21-3 / 100-7
3. Registration & Recall, Give 3 words & ask to repeat.
4. Abstract: Something is Fishi
5. Judgment: Five/ Earth quack
6. Short term memory: Repeat those 3 words
7. Long term memory: DOB, PM Name
8. Insight: (Six Levels of Insight are Below)
I. Complete denial of illness
II. Slight awareness of being sick & needing help but denying it at the same time.
III. Awareness of being sick but blaming it on others, on external factors, or on
organic factors.
IV. Awareness that illness is due to something unknown in the patient.
V. Intellectual insight.
VI. True emotional insight

Diagnosis:
According to ICD 10 on
Axis I:
 Recurrent Depression, Current Episode Severe or Psychotic Feature

Different Dx:
i. Organic Anxiety Disorder (Hypothyroid)
ii. Adjustment Disorder
iii. Bipolar Anxiety Disorder (BPAD)
iv. Personality Disorder

Axis II:
 Functionality impairment

Axis III:
 Predisposing Factor: + Family History
 Aggravating Factor: Marital Conflict, Financial Issues, Diverse/ Family Stressor
 Maintaining Factor: Poor Compliance of Medicine

Assessment
 I will admit Patient
 To complete Assessment for convert to Dx Based on Bio – Psycho – Social Model

Biological Assessment
 CBC
 Urea/Creatinine

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Balochistan Institute of Psychiatry and Behavior Science

 HBsAg
 Anti HCV
 HIV
 ECG
 Thyroid Profile
Psychological Assessment
 Back Depression Scale
 Hemelton Scale
 YMR ( ) Scale

Social Assessment
Collateral History from
 Spouse
 Parents/ Sibling
 Friends

Treatment
 After complete assessment and development, Dx (Diagnose) will treat my patient
based on Bio – Psycho – Social – Model.

Biological Tx (Treatment)
Pharmacotherapy
o Anti depressant
o Anti psychotic
o Mood stabilizer
o Short term Benzodiazepine
o ECT

Psychological Tx
 Psycho Education (Mature copping skills) and information co regarding Pt
psychotic illness + Tx.
 Family Therapy: lower high expose emotion (Criticism/ Negativism)
 CBT ------ Thought Impairment and Behavioral Impairment

Social Treatment
 Financial Support
 Better Social Company
 Job/ Employment offers

Prognosis
Short term:
 Good Prognosis
 Self environment
 Close Observation & Care
 Active Treatment

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Balochistan Institute of Psychiatry and Behavior Science

 Family support

Long term:
 Not Favorable
 Family Hx
 Multiple Episodes and relapse
 Multiple Stresses
 Female Gender
 Poor copping skills
 Multiple Suicidal Attempts

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