Clinical Examination of the Psychiatric Patient

Lucie Bankovská Motlová

Clinical examination of the psychiatric patient

• Identifying data• First impression• Family history• Alcohol and other substances history• Personal history• Previous psychiatri illnesses• History of present illness• Mental status examination• Diagnosis and differential diagnosis• Further diagnostic studies• Treatment plan• Summary

Identifying Data

• Name, date of birth, address• Contact information• Contact information of close person• Insuarance company• Who referrered the patient• Reason for clinical examination

First „Impression“

• Looks older than his age, bizarre appearance, tattoo, moist hands, perspiring forehead, tense posture, wide eyes,..

Family History

Goal: is there any possible genetic load or other psychosocial problem in family environment?

• Elicited from patient and (with patient´s consent) from someone else, since quite different descriptions may be given by the same people and events

• Family history of neuropsychiatric illness, drug abuse, criminal activity and suicide

• Present relationships between patient and those who were in family

Previous and Current Medical Illnesses

Goal: is there any somatic illness connected with psychiatric symptoms? Is there any medication possibly interfering with psychiatric treatment?

• Allergy, hay fever, arthritis, colitis, rheumatoid arthritis, recurrent colds, skin conditions;

• medical conditions: follow customary review of systems;

• sexually transmitted diseases;• at risk for acquired immune deficiency syndrome

(AIDS); • neurological disorders: headache, craniocerebral

trauma, loss of consciousness, seizures or tumors• Females: gynecological and obstetrical history

Treatment?

Early Childhood (through age 3)

Goal: was there any developmental delay? Were there any adverse psychosocial events?

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

• Feeding habits: breast-fed or bottle-fed, eating problems• Early development: maternal deprivation, language development,

motor development, sleep pattern, stranger anxiety, separation anxiety

• Toilet training: age, attitude of parents, feelings about it• Symptoms of behavior problems: thumb sucking, temper tantrums,

tics, head bumping, rocking, night terrors, fears, bed wetting or bed soiling, nail biting, masturbation

• Personality and temperament as a child: shy, restless, overactive, withdrawn, studious, outgoing, timid, athletic, friendly patterns of play, reactions to siblings

Childhood (ages 3 to 11)

Goal: was there any developmental delay? Were there any adverse psychosocial events? Were there problems with early adjustment?

• early school history—feelings about going to school • early adjustment, • gender identification, • punishment; • social relationships, • attitudes toward siblings and playmates

Later Childhood (Prepuberty through Adolescence)

• Peer relationships: number and closeness of friends, leader or follower, social popularity, participation in group or gang activities, idealized figures; patterns of aggression, passivity, anxiety, antisocial behavior

• School history: adjustment to school, relationships with teachers—teacher's pet or rebellious extracurricular activities, sports, hobbies, relationships of problems or symptoms to any school period

• Cognitive and motor development: learning to read and other intellectual and motor skills, minimal cerebral dysfunction, learning disabilities—their management and effects on the child

• Particular adolescent emotional or physical problems: nightmares, phobias, masturbation, bed wetting, running away, delinquency, smoking, drug or alcohol use, weight problems, feeling of inferiority

• Psychosexual history: sex play, acquiring of sexual knowledge, attitude of parents toward sex, sexual abuse; Onset of puberty, development of secondary sexual characteristics

Adulthood

• Educational and occupational history • Social activity• Adult sexuality, marital and relationship history• Military history • Current living situation• Legal history• Driving and gun licence

Alcohol or Other Substances History

Past Psychiatric Illnesses

• „When was your first contact with psychiatry?“• emotional or mental disturbances• type of treatment • names of hospitals • length of illness • effect of treatment

History of Present Illness

• chronological background and development of the symptoms or behavioral changes that culminated in the patient's seeking assistance;

• patient's life circumstances at the time of onset; • how illness has affected life activities and personal relations—

changes in personality, interests, mood, attitudes toward others, dress, habits, level of tenseness, irritability, activity, attention, concentration, memory, speech;

• psychophysiological symptoms—nature and details of dysfunction; level of anxiety—generalized and nonspecific (free floating) or specifically related to particular situations, activities, or objects; how anxieties are handled—avoidance, repetition of feared situation, use of drugs or other activities for alleviation

Use patient´s own words

History of Present Illness

• What brought you here?

• Tell me more about how did this start?

• What is worst?

• How do you feel now? (Scale 1-10, 1 is worst 10 is best)

Mental Status Examination

Goal: to summarize all symptoms based on

1. Interview with the patient

2. Observation of his/her behaviour

3. Objective information

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Mental Status Examination: Outline• Alertness and level of consciousness (clouding, somnolence, stupor)• Orientation (to time, place, person)• Appearance (healthy, sickly, bizarre, moist hands, perspiring forehead, tense posture, wide eyes)• Attitude toward examiner (cooperative, friendly, attentive, seductive, apathetic, hostile)• Behavior and psychomotor activity (mannerism, tics, echopraxia, hyperactivity, restlessness, purposeless activity)• Concentration and attention (subtracting serial 7s).• Speech (quantity, rate of production, quality: talkative, unspontaneous, monotonous, loud, slow, pressured)• Mood (depressed, despairing, irritable, anxious, angry, euphoric, empty, guilty, frightened)• Affect (within normal range, constricted, blunted, flat, difficulties in initiating, sustaining or terminating an emotional

response)• Perceptual disturbances (hallucinations, illusions; auditory, visual, olfactory, tactile, depersonalization, derealization)• Thought (form: flight of ideas, loose associations, blocking, circumstantiality, tangentiality, clang associations, neologisms;

content of thought: delusions, ideas of reference, obsessions, phobias, poverty of content)• Abstract thinking (proverbs)• Fund of information and intelligence• Memory (registration, retention and recollection of material) • Cognition (Mini Mental State Examination, MMSE)• Judgment (capability for social judgment: “What would you do, if you smelled smoke in a crowded movie theater?”)• Reliability (capacity to report situation accurately)• Insight (degree of awareness and understanding that they are ill)• Suicide ideation, plan• Impulse control (is the patient capable of controlling sexual, aggressive, and other impulses?)

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• Video: Clinical Examination of Psychiatric Patient (40 minutes)

Diagnosis and Differential Diagnosis

ClassificationICD-10 Europe; DSM-IV-USA

Diagnosis and Differential Diagnosis

• Axis I: clinical syndromes (e.g., mood disorders, schizophrenia, generalized anxiety disorder) and other conditions that may be a focus of clinical attention

• Axis II: personality disorders, mental retardation, and defense mechanisms

• Axis III: any general medical conditions (e.g., epilepsy, cardiovascular disease, endocrine disorders)

• Axis IV: psychosocial and environmental problems (e.g., divorce, injury, death of a loved one) relevant to the illness

• Axis V: global assessment of functioning exhibited by the patient during the interview (e.g., social, occupational, and psychological functioning); a rating scale with a continuum from 100 (superior functioning) to 1 (grossly impaired functioning) is used

Further diagnostic studies

• Physical examination (obligatory for all inpatients)

• Neurological examination?

• Additional psychiatric diagnostic interviews?

• Interviews with family members, friends, or neighbors by a social worker?

• Psychological, neurological, or laboratory tests as indicated: electroencephalogram, computed tomography scan, magnetic resonance imaging, tests of other medical conditions, reading comprehension and writing tests, test for aphasia, projective or objective psychological tests, dexamethasone-suppression test, 24-hour urine test for heavy metal intoxication, urine screen for drugs of abuse

Obligatory tests

• White blood count before clozapine treatment (and during the course of treatment)

• Creatinine clearance before lithium treatment

• Lithium blood levels

Treatment plan

• Modalities of treatment recommended, medication?

• Inpatient or outpatient treatment? • Psychotherapy?

• Initially, treatment must be directed toward any life-threatening situations such as suicidal risk or risk of danger to others, which require psychiatric hospitalization.

Summary

Goal: to briefly summarize information relevant to diagnosis and treament for quick orientation in case of an emergency

Age, current diagnosis (mental illness and somatic dg), medication including side-effects or contraindications, dangerousness to self or others