2. Assessment is
defined as a systematic
and continuous collection
of data on the health
status of a patient.
Subjective
data Objective
data
2
3. ⢠To describe the patientâs condition, family, development and
environmental fators affecting the behaviour.
⢠To find out the predisposing and primary cause of his
behaviour.
⢠To make nursing diagnosis.
⢠To identify psychiatric emergencies.
⢠To plan nursing interventions.
3
4. History taking
Mental status examination
Medical investigations,
Neuroimaging techniques,
Psychological tests
Health education
4
5. Psychiatric History Taking
I. Identification Data:
Name:
Age:
Gender:
Marital Status:
Fatherâs name/Husbandâs name:
Education:
Occupation:
5
7. II. Chief Complaint:
According to patient:
According to informant:
Informantâs name:
Relationship with patient:
Intimacy with the patient:
Does the informant live with the patient:
Duration of relationship with the patient:
Bias with the patient:
Interest of informant in the patientâs property/money:
Reason for consultation:
Reliability of information:
Adequacy of information:
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8. III. History of Present Illness:
Predisposing factor:
Precipitating factor:
Perpetuating factor:
Mode of onset: Abrupt/Acute/Insidious
Course:Continuous/Episodic/Fluctuating/
deteriorating/unclear
Intensity: Same increasing/decreasing
Progression: Improving/Deteriorating/Static
Chronological development of symptoms/ behavior
Patient's life circumstances at the time of onset
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9. Treatment history
⢠Drugs
⢠ECT:
⢠Psychotherapy:
⢠Family therapy:
⢠Rehabilitation:
Date Duration Mode of
treatment
Drugs Side
effects
Response Adherence Outcom
e
Remarks
IPD/OPD
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10. IV. Past History of Illness:
Past Medical/Surgical history:
Past Psychiatric history:
V. Family History: (from patient and other member of the family)
Type of family
Decision maker in family:
Source Of Income:
Role of patient in the family:
Family history of mental illness:
Family Genogram:
Description of family members:
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12. VI. Personal History:
⢠Perinatal History
ďŻAntenatal period: Maternal infections/exposure to
radiation/any other/Check-ups Any complications
ďŻIntra-natal period: Type of delivery-
normal/Instrumental/caesarian/ Any complications
ďŻBirth: Full-term / premature/post-mature
ďŻBirth cry: Immediate/delayed
ďŻBirth defects: Yes or no, if yes, specify
ďŻPostnatal complications:
Cyanosis/convulsions/jaundice/neonatal infections any other
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13. ⢠Childhood History
ďŻPrimary caregiver:
ďŻFeeding: Breastfed/artificial mode of feeding
ďŻAge at weaning
ďŻDevelopmental milestones and Behavior and emotional
problems: Thumb sucking/excessive temper tantrums/stuttering/
head hanging/body rocking/nail biting/pica enuresis/morbid
fears/night terrors/somnambulism
ďŻIllness during childhood: Specifically for CNS
infections/epilepsy/neurotic disorders/malnutrition
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14. ⢠Educational history
⢠Play history
⢠Emotional problems during adolescence
⢠Puberty
⢠Adulthood
⢠Obstetrical History:
⢠Occupational history:
⢠Sexual history
⢠Addiction history (Onset/ Amount/Maximum intake/History of
withdrawal/Abstinence)
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15. VII. Pre-morbid Personality
⢠Interpersonal relationships Family and social relationships:
Extrovert/introvert
⢠Family and social relationships
⢠Use of leisure time: Optimistic/pessimistic; stable/fluctuating
⢠Predominant mood: cheerful/despondent
⢠Usual reaction to stress:
⢠Attitude to self and others:
⢠Religious beliefs and moral attitudes
⢠Fantasy life: Daydreaming frequency and content
⢠Habits:
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18. IV. General Appearance and Behavior:
Appearance: Looking oneâs age/looks older/younger than his
age/underweight/overweight/physical deformity
Facial expression: Anxious/blunted/pleasant/fearful
Level of grooming: Normal/shabbily dressed/overdressed/idiosyncratically
dressed Adequate/inadequate/overtly clean
Level of cleanliness:
Level of consciousness: Fully conscious and alert/confused/clouding of
conciousness/drowsy or somnolence/stuporous/comatosed/delirium/dream state
Mode of entry: Came willingly/persuaded/brought using physical force
Behavior: Normal/over friendly/preoccupied/aggressive
Co-operativeness: Normal/more than so/less than so
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19. Eye-to-eye contact: Maintained/difficult/not maintained
Psychomotor activity: Normal/increased/decreased
Rapport: Spontaneous/difficult/not established
Gesturing: Normal/exaggerated/odd
Posturing: Normal posture/catatonic posture/stooped/stift/guarded
Other movements: Normal/stereotype/tremors/extrapyramidal
symptoms/abnormal movements
Other catatonic phenomena: Automatic obedience/negativism/excessive co-
operation/waxy flexibility/ echopraxia/echolalia
Conversion and dissociative signs: Pseudoseizures/possession states/any other
Compulsive acts or rituals or habits (for example nail biting):
Hallucinatory behavior: Smiling or crying without reason/muttering or talking to
self, odd gesturing
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20. V: Talk and Speech:
Initiation: Spontaneous/speaks when spoken to/minimal/mute
Reaction time (time taken to answer the question): Normal/delayed/shortened/difficult to assess
Rate: Normal/slow/rapid
Productivity: Monosyllabic/elaborate replies/pressured Volume: Normal/increased (loud)/decreased
(soft)
Tone: Normal variation/high pitch/low pitch/monotonous
Relevance: Fully relevant/sometimes off target/irrelevant (answer the question appropriately)
Stream: Normal/circumstantial/tangential/blocking/verbigeration/stereotypies verbal/flight of
ideas/clang associations (flow and rhythm of speech)
Coherence: Fully coherent/loosening of associations (in coherent)
Others: Echolalia/perseveration/neologism
Sample of speech (in response to open-ended questions, verbatim in 2 or 3 sentences):
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21. VI. Mood and Affect:
Subjective:
Objective:
Predominant mood state:
Irritable/labile/blunted/anxious/fearful/panic/aggre
ssive/cheerful/depressed Appropriate (relevance to
situation and thought congruent)/inappropriate
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22. VII. Thought
⢠Formation level: Autistic/Derestic thinking
⢠progression level: Flight of ideas/Thought
retardation/Perseveration/Circumstantiality/Tangentiality/Incoherence/Blocking
⢠content level:
ďźDelusions: Specify with examples-delusion of persecution/delusion of reference/delusion of
grandeur/delusion of influence and passivity/delusion of control/hypochondrial delusion/nihilistic
delusions/delusion of infidelity/bizzare delusions
ďźIdeas: Worthlessness/helplessness/hopelessness/guilt/hypochondrial/death wishes
ďźThought alienation phenomena: Thought insertion/thought withdrawl/thought broadcasting
ďźObsessional/compusive phenomena: Thoughts/images/ruminations/doubts/impulsive rituals
ďźPhobias (irrational fears):
ďźAny preoccupations:
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23. VIII. Perception:
⢠Illusion
⢠Hallucinations (specify type with example):
auditory/visual/olfactory/gustatory/ tactile
⢠Somatic passivity
⢠Deja vu/jamais vu
⢠Depersonalization/ derealization
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24. IX. Cognitive function
Consciousness
Orientation: (Time, place, person)
Attention
⢠Normally aroused/ aroused with difficulty
⢠Digit forward
⢠Digit backward
Concentration
⢠Normally sustained/ sustained with difficulty/distractible
⢠100-7
⢠40-3
⢠20-1
⢠Names of months
⢠Names of weeks
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25. Memory:
Immediate
Recent (recent happenings, last meal, visitors etc)
Verbal recall: 3 unrelated objects
Remote (personal events, impersonal events. Illness related events)
Intelligence:
General information:
Arithmatic ability:
Abstract thinking:
Normal/concrete
Interpretation of proverbs
Similarities between paired objects, dissimilarities between paired objects
X. Judgment: (personal, social, test judgment)
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26. 26
XI. Insight:
Grade I Complete denial of illness
Grade II Slight awareness of being sick
Grade III Awareness of being sick attributed to external/physical factor
Grade IV Awareness of being sick but due to something unknown in himself
Grade V Intellectual insight : Awareness of being ill and knows the symptoms are
due to illness but is not able to use the knowledge to cope in future
Grade VI True emotional insight : Patient has awareness where the symptoms bring
changes in behaviour or personality