Beruflich Dokumente
Kultur Dokumente
PSYCHIATRIC HISTORY
Record of the patients life for the psychiatrist to
Understand WHO the patient is Where he/she has come from Where he/she is likely to go
PSYCHIATRIC HISTORY
Patients life story told to the psychiatrist
In the patients own words From his/her point of view
PSYCHIATRIC HISTORY
Most of the time, need to interview other people involved with the patient
Parents Spouses Siblings Neighbors Police Social Workers
PSYCHIATRIC HISTORY
WHEN STARTED ? FACTORS ? ILLNESS COURSE HOME REMEDY? VIEWS ON ILLNESS
Chief Complaint
MEDICAL HISTORY PSYCHIATRIC HISTORY
PSYCHIATRIC HISTORY
MEDICAL HISTORY
Chief Complaint
PSYCHIATRI C HISTORY
PSYCHIATRIC HISTORY
Looks into the patients
Strengths and weaknesses Nature of relationships with others Coping mechanisms Functionality/dysfunctionality Both patients perspective & that of significant others
PSYCHIATRIC HISTORY
Important:
let patient tell his/her story In his/her own words In the order they consider most important
PSYCHIATRIC HISTORY
Let the patient tell his/her story
You will see the gaps but dont interrupt yet In the meantime note down your questions Later, you can confront, clarify, summarize,
PSYCHIATRIC HISTORY
The PSYCHIATRIC HISTORY is only one portion of the PSYCHIATRIC REPORT
PSYCHIATRIC REPORT
Psychiatric History Mental Status Examination Further Diagnostic Studies Summary of Findings Diagnosis Psychodynamic Formulation Comprehensive Treatment Plan
(page 243246)
Identifying Data
Can be in outline form or paragraph form Provides a thumbnail sketch of potentially important characteristics
Identifying Data
Name Age Sex C.S. Address Religion Educational Attainment Contact # Occupation Source of referral Sibling rank Sources Reliability of Sources
Chief Complaint
Why the patient has come, or has been brought, or has been referred Questions may be in line with:
How can I help you today? What brings you here to the ER? Why have you come here today?
Chief Complaint
Brief statement; in verbatimthe patients own words The more, the better Get also from the family, the relatives, the police or tanod, the neighbors, and the social workers
Sample HPI
9 YRS PTA, the patient came out of the bank and claimed to hear a female voice which only he could hear. He was scared and rushed home, but the voice would not go away. 8 YRS PTA, the patient was in school and witnessed a fight. A few hours later, at home, he began to hear the same voice teasing him. He was terrified and began yelling at the voice. He was brought again to WVSUMC
Sample HPI
9 YRS PTA, the patient came out of the bank and claimed to hear a female voice which only he could hear. He was scared and rushed home, but the voice would not go away. Pts mother claimed he would point at the ceiling and yell that an aswang was there 2 Days Later, he was brought to a sirohano who said that a dwendi had a crush on the pt. The pts father did not accept this and brought the pt to the WVSUMC ER, where
YES
GATHER DETAILS ON THE CURRENT SX FOR HPI DETAILS OF THE CHRONIC ILLNESS GOES IN THE PMH YES
NO
DOES THE PATIENT HAVE A RECURRING MENTAL ILLNESS?
YES
NO
NO
Past Illnesses
Previous Psychiatric & Medical Disorders Record details of symptoms:
causes complications extent of incapacity type of Tx received & their effects names of hospitals length of each illnesses
Past Illnesses
Ask for the use of alcohol or other substances
What type of alcohol? Cigarettes? Designer drug? When started and how much taken then? Did it gradually increase? How? Taken alone or with others? Ever try to stop? Did you feel anything different in your body when you tried?
Past Illnesses
Ask for:
Previous operations or consultations Body markings History of neurological disorders or symptoms of convulsions, fainting spells, double vision Previous trauma Previous medications
Family History
Any psychiatric illness, hospitalization, & treatment Hx of alcohol & other substance abuse Description of personalities & intelligence of various persons in w/c Pt lived
Family History
List down each member & note their sex, age, civil status, educational attainment, their occupation Role of each person who played in Pts upbringing Family ethnic, national, religious traditions
Family History
Familys attitude toward, & insight into Pts illness How the Pt feels about his family members: supportive? Most trusted? Most distrusted? Role of illness in the family
PERSONAL HISTORY
CURRENT LIVING SITUATION
Companions at home Relationship with each What kind of work able to do Able to groom self/ take care of others How gets along with neighbor(s)
PERSONAL HISTORY
SEXUAL HISTORY:
Sexually active Any changes or problems with sex Acquisition of sexual knowledge Onset of puberty/menarche
PERSONAL HISTORY
SEXUAL HISTORY:
Development of sexual identity & orientation First sexual experiences Sex in romantic relationship Changing sexual preferences
PERSONAL HISTORY
VALUES:
Social & moral work, money, play, children, parents, friends, sex, community concerns, & cultural issues Are children a burden or joy?
PERSONAL HISTORY
VALUES:
Is work a necessary evil, an avoidable chore, or an opportunity? Patients concept of right & wrong
PERSONAL HISTORY
FANTASIES & DREAMS:
Repetitive dreams Nightmares Recent dreams & meanings Fantasies & daydreams Details of fantasy & attendant feelings