1. History taking ,psychiatric interview
Dr Maha Suliaman Younis
Assistant professor in Psychiatry

2. Identifying Data Name ,Age ,Sex , Address ,marital status
Occupation –students? Employment ? Un employed ?retired .governmental ,regular, for women ;house wife
Education –failure at school ,leaving for social reasons
Religion ,race ?
Referral source ,reason for reference,source

3. Collateral information (informant )
Next of kin ,friend ,spouse ,others
To validate reliability of the patients history ,to add feed back ,in cases of drug addiction ,personality disorders, mental confusion,dementia or any other cognitive defect
Chief complain (in patients own words )include duration

4. History of present illness
Reasons for seeking medical help that day
Current symptoms
Onset ,duration ,course, stressor ,relevant associated symptoms (positive ,negative)
Past psychiatric history –previous ,contact with psychiatrist ,sometimes faith healers psychiatric disorders ,previous hospitalization in chronological order with dates
Past suicidal attempts ,legal history, substance abuse

5. Family history
Presence of psychiatric history in the close relatives (even the dead)
Relation ships with his family members
Past medical history, chronic physical illnesses, medications ,neurological disorders
Caffeine use ,smoking

6. Past personal history
Early Childhood history ,prenatal ,birth history ,post natal illnesses ,middle childhood ,adulthood
Pre morbid personality, history from patient and close relative usually parents.
Schooling ,during childhood and adolescence
Psychosexual history ,legal history

7. Mental state examination
Appearance ,grooming ,posture ,gait physical appearance, body gesture ,facial expression (sad ,gloomy, anxious ,apprehensive, happy, suspicious )attitude toward examiner (ability to I
nteract ,level of eye contact, psychomotor activity (agitation ,retardation )abnormal movement 9tardive dyskinesia, tremor ,akathesia) body gesture

8. Speech Rate; -mute ,slow ,pressured Volume Tone fluency Articulation
Quantity
spontaneity

9. Mood and Affect
Mood :subjective emotional state in the patients own words
Affect : Objective Emotional state in terms of quality
-euthymic ,depressed ,elevated ,anxious
Range ; full ,restricted
Stability ;fixed ,labile
Intensity : flat ,blunted
Appropriateness

10. Thought disorders
Presence of delusions
Presence of perceptual disorders (hallucinations)
Differences between true and pseudo hallucinations
Any associated medical or neurological symptoms

11. Cognitive assessment
To evaluate the cognitive state of the patient and exclude any acute defect or dementing process
1-conscousness
2-Attention
3- concentration
4- orientation to
-time
-place
-person

12. Cognitive assessment Memory assessment -Instant memory Short memory
-Intermediate memory
-Remote memory
Intelligence
-general knowledge (cultural factors had to be considered always )
-Mathematical problem (for the illiterates, had to be within the patients field of experience )
Judgment :problem solving ability
Insight

13. Insight
Present (preserved)
Loss
Partially preserved
In suspected patients of acute or chronic brain disorders mini mental state examination (scored test) is preferred to be applied

14. Neurological and physical examination
Is it important ?
Careful physical and neurological examination had to be done when history of the patient or his family is suggestive otherwise routine examination and investigations is to follow
Investigations
As the history suggest further than the routine one

15. Summery
Formulation of the case is to be done in 5-6 line mentioning the positive and important negative symptoms and sign ,family history should be mentioned
Provisional diagnosis with second and third deferential diagnosis
Management plan ;admission to psychiatric unit ,outpatient follow-up ,drug adminstration,oral ,i.m,i.v, ,ECT,non drug therapy like psychotherapy ,occupational ,behavioral

16. Interviewing technique
Technique : 1-support : to establish rapport
2-empathy ;To express doctors understanding
3-validation; to give credence and value to the patients feelings

17. Interviewing technique
1-open ended question : to obtain much information without leading question
2-Facilitation ; to encourage patient to elaborate on an answer may be verbal ore body language
3-Reflection ; to encourage the patient to expand on the answer by repeating part of the patient previous response
Silence ; to increase the patients responsiveness

18. Diagnostic tests in psychiatry
Psychological tests to assess functioning ;intelligence ,personality ,psychopathology
Objective ; questions with right or wrong answers and projective tests questions require interpretation of the answers and responses
-Cognitive tests ;I.Q
Personality ; MMPI,, Rorschach test
Neuropsychological test ; to detect the localized brain lesions like Halstead –Reitan Batterytest

19. Biological Evaluation
Measurement of biogenic amines;change in caticolamines
Plasma levels of anti psychotics and antidepressants drugs
Dexamethasone suppression test (DST)with the normal hypothalamic –adrenal –pitutary axis
Endocrine functioning

20. EEGand evoked potential
Tests
CT-
MRI
PET
EEG
EEGand evoked potential