Clinical Examination of the Psychiatric

Patient

By Tadesse M
Msc. In ICCMH

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Clinical Examination of the Psychiatric Patient

A. Psychiatric history
B. Mental status examination

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 A. Psychiatric History

Purpose
• To gather information that will enable the examiner to
make a diagnosis.
• Psychiatry has no external validating criteria
• No laboratory tests
• Diagnosis can ever be better than the judgment made
by individual clinicians.
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 Psychiatric History
 Is the record of the patient's life

• It allows a you to understand

– Who the patient is

– Where the patient has come from,

– Where the patient is likely to go in the future.

• Includes information about the patient obtained from other sources

– Parent

– Spouse

– Colleagues
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 Components psychiatric history

I. Identification
II. Chief complaints
III. History of presenting illness
IV. Past psychiatric history
V. Past medical history
VI. Family history

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 Components psychiatric history cont.

VII. Personal history

VIII. Sexual history
IX. Forensic history
X. Premorbid personality

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 I. Identification
Provide a succinct demographic summary of the patient
by
– Name, age, sex, marital status
– ethnic background and religion
– Educational status, occupation
– Patient's current living circumstances
– Source information

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 Identification data cont’d
- Whether the patient came in
– On his or her own
– Referred by someone else
– Brought in by someone else.
– the reliability of the source(s)
– Whether the current disorder is the first episode
for the patient.

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 II. Chief Complaints

 A verbatim recording of the patient's reason for seeking

treatment or evaluation

 Put the chief complaint in the patient's own words, even if

implausible or illogical or absurd,

 Duration of the chief complaint (if the patient is able to

cooperate)
 What do you think is your main problem?
 What brought you to the hospital?
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III. History of the Present Illness
 The last time the patient was well (helps to establish the

whole course of the illness)

 Take a detailed account of the illness from the earliest

time at which a change was noted until consultation.

 Mode of onset

 a chronological description of how symptoms developed

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Whether help is sought and if yes where and when and
for how long he or she has been there
The impact of the current patient’s psychiatric illness
on
 Occupational area
 Interpersonal relationships
 The self
 caregivers
The immediate or remote precipitating factors and
relieving factors

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Any current alcohol or other substance use should
be described, including
amounts,
frequency, and
last use
Substance misuse history

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Suicide
 death wish,
 Suicidal ideation
 degree of suicide intent,
 contemplated methods of carrying out
suicidal acts,
 suicide plan,
 plans and attempt during previous episodes,
impulsive suicide attempt, other self injurious
acts)
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IV. Past Psychiatric History
 Was the illness similar or different?
 Any previous admissions (how many)
 Has there been interepisode symptom free period
functioning
 The type of medications prescribed and the dose
 Any drug side effects then?
 Was the patient compliant or not, if not the reasons
for it
 History of suicidal, homicidal behavior
 substance abuse during past episodes

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V. Past Medical/surgical History
 medical conditions
 sexually transmitted diseases
 Head injury
 Epilepsy

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VI. Family history
 Any psychiatric illness, hospitalization, and
treatment of the patient's immediate family
members
 Family history of suicide
 Family history of alcohol and other substance
abuse
 The family's attitude toward, and insight into, the
patient's illness
 Patient's attitude toward each of his parents and
siblings

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VII. Personal History
 history of the patient’s life from infancy to the present to
the extent it can be recalled;
 Prenatal and Perinatal
 Early childhood (through age 3)
 Middle childhood (age 3- 11)
 Late childhood puberty through adolescence)
 Adulthood
gaps in history as spontaneously related by the patient;
emotions associated with different life periods (painful,
stressful, and conflictual) or with phases of the life cycle.
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 Outline of a Developmental History

Prenatal and perinatal

– Full-term pregnancy or premature
– Vaginal delivery or caesarian
– Drugs taken by mother during pregnancy
(prescription and recreational)
– Birth complications

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• Prenatal history and mother’s pregnancy and
delivery:
• length of pregnancy,
• spontaneity and normality of delivery,
• birth trauma,
• whether the patient was planned and
• wanted, birth defects

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Outline of a Developmental History cont.
• Infancy and early childhood
– Infant-mother relationship
– Problems with feeding and sleep
– Significant milestones
• Standing/walking
• First words/two-word sentences
• Bowel and bladder control
– Other caregivers
– Unusual behaviors (e.g., head-banging)

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Outline of a Developmental History cont.

• Middle childhood
– Preschool and school experiences
– Separations from caregivers
– Friendships/play
– Methods of discipline
– Illness, surgery, or trauma

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Outline of a Developmental History cont.

• Adolescence

– Onset of puberty
– Academic achievement
– Organized activities (sports, clubs)
– Areas of special interest

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Outline of a Developmental History cont.

• Young adulthood
– Meaningful long-term relationship
– Academic and career decisions
– Military experience
– Work history
– Prison experience
– Intellectual pursuits and leisure activities

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 VIII. Forensic History:

– List of offences/charges & legal outcome.

 Have you ever been in trouble with the police?
 any violent/sexual crimes and persistent
offending.
• IX. Sexual History
• Screening questions
– Are you sexually active?
– Have you noticed any changes or problems with
sex recently?

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 Sexual History cont’d

• Developmental
– Onset of puberty/menarche
– Development of sexual identity and orientation
– First sexual experiences
– Sex and advancing age
– Clarification of sexual problems

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X. Fantasies and Dreams

• Repetitive dreams have particular value.

• Fantasies and daydreams are another valuable
source of unconscious material.
• What are the patient's fantasies about the future?

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XI. Premorbid personality

• How would you describe yourself?

 How would other people describe you?
 When you find yourself in difficult situations, what do
you do to cope?
 What sort of things do you like to do to relax?
• Do you have any hobbies?
• Do you like to be around other people or do you
prefer your own company?

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 II. Mental State Examination
• Mental status examination of psychiatric patient is
analogous to the P/E of a medical patient.
 MSE provides a format for the systematic
observation and recording of information about
– Patient’s thinking
– Patient’s emotions
– Patients behavior

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 MSE data combined with information fro the history
are the basis for formulating a diagnosis
– Note only those findings found only at the time of
MSE
– Exclude historical data
– Much of the MSE data is observational and can be
made at the time of taking history

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 Outline for the Mental Status Examination
6. Perceptions
7. Sensorium /cognition
– Alertness
– Orientation (person, place, time)
– Memory (immediate, recent, long term)
– Concentration
– Fund of knowledge
– Abstract reasoning
8. Judgment and Insight

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 General Description
• Appearance:
Dress might be untidy ,with buttons undone, or done
incorrectly, worn torn or it might in adequate or the
weather.

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 General description cont.
• Self neglect: Men may appear unshaven , the face may be
unwashed, hair uncombed.

• Women may wear no makeup or they may apply their makeup

carelessly.

• Unusual accessories: patient sometimes pack there

pockets with there belonging or carry a large holders of
personal possessions or paper manuscripts

• Finger nails might be long and dirty

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 General description cont
• GAIT : Unusually slow, fast, unusual character of gait.
• Eye contact
• Psychomotor activity : Tic, Tardive Dyskinesia,
Stereotypes, Mannerism, Posturing, Negativism,
• Attitude towards the interviewer

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Speech
• Speed: fast, slow ,and normal
• Volume: Loud , Low, Normal
• Quantity: Too little, too much or normal
• Tone : Low pitched, high pitched
• None-social speech: muttering ,neologism, ward salad

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 Emotion
• Mood: you evaluate the mood by asking the feeling of the
patient:
sadness, elation, anxious, labile, euthymic, expansive
• Affect: what the interviewer observing during the
interview
• read it from facial expression of the patient

• Flat , constricted, appropriate, inappropriate,

normal range , labile

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Thought
•FORM:

– flight of ideas ,circumstantialities, tangentially,

– loosing of association, Clang association, thought

blocking, Neologism, pressure of thought

•CONTENT: Delusion , compulsion, idea of reference,

hypochondria, obsession, hopelessness, Suicidal

ideation, preoccupation
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Perception
– Hallucination

– Illusions
– Depersonalization
– Derealization

Cognition and sensorium

– Alertness and level of consciousness
– Orientation: to time, place ,person
– Memory: Remote , Recent and Immediate
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– Immediate memory

• Repeat these numbers after me: 1, 4, 9, 2, 5.   

– Recent memory

• I want you to remember these three things: a yellow pencil,

a white paper, and a black coat. After a few minutes I'll ask
you to repeat them.

• Also memories of past few days

– Recent past memory – past few months

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 – Long term memory
• What was your address when you were in the third
grade/ married?
• Who was your teacher/?
• What did you do during the summer between high
school and college/ when the EPRDF took power
• Concentration and attention
• Abstract thinking: the ability to deal with concepts
• General knowledge; depend on patient’s educational level

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Judgment
• The patient's capability for social judgment
• Can he/she understand the likely outcome of his or her
behavior
• Can the patient predict what he or she would do in imaginary
situations
Insight
The patient's degree of awareness and understanding about
being ill.

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 General Medical Screening of the Psychiatric
Patient

A thorough physical and neurological examination, including basic

screening laboratory studies to rule out physical conditions,
should be completed.
A. Laboratory evaluation of the psychiatric patient

1. CBC with differential

2. Blood chemistry

3. Thyroid function test.

4. Screening test for syphilis (RPR)

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– 5. Urinalysis with drug screen.

– 6. Urine pregnancy check for females of child bearing potential.

– 7. Blood alcohol level.

– 8. Serum levels of medications.
– 9. HIV test in high-risk patients.

B. Amore extensive workup and laboratory studies maybe indicated based on clinical
findings
• CT SCAN
• MRI

• EEG

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 Multi axial diagnosis

• Evaluation of patients using several variables

• 5 axis each of which refers to a different domain of
information
• Axis I: clinical diagnoses and other conditions that
may be a focus of clinical attention
• Axis II: personality disorder/Mental retardation
• Axis III: Physical disorder or general medical condition
• Axis IV: Psychosocial environmental problems that
may affect the diagnosis, treatment and prognosis of
mental disorder
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 Multi axial diagnosis cont
Axis V: global assessment of functioning
• Reporting the clinician's judgment of the individual’s
overall level of functioning.
• The information is useful in planning treatment and
measuring its impact and in predicting outcome.

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 Formulation biopsychosocial
Biological psychological Social

Predisposing

precipitating

perpetuating

protective

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Thank you !!!

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