Psychiatry Practical PDF

Dr.Para Dise 1 Dr.Para Dise N.O Chapter Page 1 Symptoms and signs of psychiatric disorders 3 2 Psychiatry case taking 18 3 Check lists...

Dr.Para Dise 1 Dr.Para Dise N.O Chapter Page 1 Symptoms and signs of psychiatric disorders 3 2 Psychiatry case taking 18 3 Check lists 30 2 Dr.Para Dise In this chapter we are going to discuss the clinical symptoms and signs of the different fields of mental functions: Behavior Emotions Intellect (I) Symptoms & Signs of Behavior Clinical psychiatric symptoms may occur in different fields of human behavior including: Quantitative disturbance Motor behavior Qualitative disturbance Disturbance of the phases of sexual act Sexual behavior Disturbance of object selection Disturbance of sexual identity Insomnia Hypersomnia Sleeping behavior Parasomnia Narcolepsy Social withdrawal Social avoidance Social behavior Social disinhibition Anti-social behavior Anorexia nervosa Bulimia nervosa Eating behavior Binge eating Pica 3 Dr.Para Dise A- Motor behavior 1. Quantitative disturbance: It means increase or decrease of the motor behavior to a pathological level. It means increased motor activity as wringing Agitation Depression hands, shouting or loud complaining Increased motor activity with feeling of inner Restlessness Anxiety tension and inability to sit or stand still Severer form of agitation and it sometimes Excitement Psychosis involves aggressive and destructive behavior It is a form of restless behavior that occur as drug side effect Akathesia pointing to extra pyramidal pathology Slowness of motor activity - In depression the retarded motor activity is due to lack of Retardation interest which is a component of the depressed mood. - In schizophrenia it is due to “avolition” which mean that the patient has no will power to do or initiate an act. Complete or marked suppression of motor activity, although the patient feels and perceives the external and/or internal stimuli he does not react to them at all. Stupor No profound effect on conscious level. This means that patient is arousable but not responsive which occur in schizophrenia, depression, and organic mental disorders. 4 Dr.Para Dise 2. Qualitative disturbance: It means occurrence of new abnormal modes of motor behavior: (Catatonia) This is a purposeless repetition of movement. Stereotypy This could be: 1. Repetition of movement e.g., walking 4 steps forward then 4 backward or 2. Repetition of words like saying I am here; I am here without any good reason to do or say this. Purposeful repetition of movement i.e., keeping with the Mannerism patient belief. The beliefs are usually delusional. Repetition of the same act in spite of the patient effort or Perseveration desire to do a new one i.e., difficulty to switch from one act to a new one. Negativism Doing the opposite of what asked for. Resistance Automatic resistance to all stimuli. They are manifestations of childhood oppositional Negativism and disorders, some types of personality disorders and some resistance psychotic conditions. Echopraxia Pathological imitation of movement seen. Echolalia Pathological imitation of words heard. Catalepsy Passive induction of a posture held against gravity Waxy flexibility Allow positioning by examiner and maintain position. Other manifestation of catatonia: stupor, mutism, grimacing. Features of catatonic behavior could be found in: - Schizophrenia - Drug intoxication - Major depression - Organic brain diseases. 5 Dr.Para Dise B. Disturbance of sexual behavior The disturbance of sexual behavior could in the following areas: 1. Disturbance of the phases of sexual act Disturbance of desire: (diminished as in depression or increased as in mania) Disturbance of arousal Disturbance of orgasm 2. Disturbance of object selection e.g., getting aroused by non-human object (Paraphilia) 3. Disturbance of sexual identity Gender dysphoria: In this condition there is long term non satisfaction and discomfort of the one's biological sex e.g., a boy who is biologically male but he is not accepting being a boy and wants to change his sex to become a girl. C. Disturbance of sleep behavior 1. Insomnia: Difficulty to initiate or maintain sleep or the sleep is not causing restoration (rest) (it may be initial, late, total insomnia and/or frequent awakenings). 2. Hypersomnia: longer than normal period of sleep or excessive daytime sleep 3. Parasomnias: abnormal phenomena during sleep. a) Night mares: bad dreams which patient can remember them. b) Sleep terrors: awaken terrified, confused and can’t remember. c) Sleep walking and sleep talking. 4. Narcolepsy: sleep attacks with loss of muscle tone. 6 Dr.Para Dise D. Disturbance of social behavior 1. Social withdrawal: Don’t mix with people and don’t want to mix as in schizophrenia. 2. Social avoidance: Want to mix but can’t mix with people as in social phobia. 3. Social disinhibition: Disregarding social norms as in mania 4. Antisocial behavior: Violating rules and laws as in antisocial personality and conduct disorder E. Disturbance of eating behavior 1. Anorexia nervosa 2. Bulimia Nervosa 3. Binge eating disorder 4. Pica: eating non-nutritive substance as in nutritional deficiency, pregnancy or dementia. 7 Dr.Para Dise (II) Symptoms & Signs of Emotions Emotion: It is complex feeling state accompanied with psychic, somatic and behavioral changes. Emotions are two components: - Emotional experience: the inner feeling and the - Emotional expression: through face or body and observed by others. Affect: It is the subject’s inner feeling or experience at a given moment. Affect or feelings may be - Pleasant e.g., happiness or love - Unpleasant e.g., sadness, hate, fear, guilt, shame, disgust and anger. Mood: It is the pervasive and sustained emotion 8 Dr.Para Dise Emotional disturbances can be grouped under two categories. Quantitative disturbance. Qualitative disturbances. 1- Quantitative disturbance In which the normal emotions are either pathologically increase or decrease: It means happiness or gladness. Elation It is pathological when exceeds the patient's actual circumstances Occurring in mania Generalized feeling of wellbeing (i.e., Elation plus sense of satisfaction). Euphoria Present in different psychiatric disorder e.g., drug addiction, mania, schizophrenia and organic brain syndromes. Elation accompanied by grandiose feeling, occurring in Exaltation psychotic states like mania and schizophrenia. Elation accompanied by spiritual or mystical feeling. Ecstasy Occurs in some cases of schizophrenia. An emotional state characterized by triad of: 1. Pervasive lack of interest. Depression 2. Difficulty to feel pleasure (anhedonia). 3. Sadness not in accord with the patient's actual circumstances. 9 Dr.Para Dise It is a complex symptom with cognitive emotional and behavioral components. The cognitive component is irrational anticipation of danger. Anxiety - If the source of anticipation is unknown it is called generalized anxiety - if the anticipation is from potentially non dangerous object or situation it is called phobia - if the anticipation is from consequences of act or situation it regarded as obsessive fear The emotional component is that of fear while the behavioral one is agitation and restlessness. Absence of affect, or loss of emotion, or lack of feeling (There is loss of both Apathy emotional expression and experience). Occurs in some schizophrenics. la belle Occurs in hysteria when the patient feels happy in spite of his indifference disability. The emotional change from one extreme to the other with Emotional no obvious cause (e.g., Laughing and weeping). lability It occurs in gross organic lesions of the brain e.g., the pseudo bulbar syndrome. It is an unprovoked transient angry outburst with violence. Morbid anger (In children and mentally defectives, it is called 'tantrums'). Occurs in schizophrenia and personality disorders 10 Dr.Para Dise 2- Qualitative disturbances: Emergence of abnormal or inappropriate emotions: 1. Incongruity of affect: Inappropriateness of affect to thought content (e.g., the patient feels happy while he believes that he is going to be killed by his enemies). 2. Ambivalence: Simultaneous existence of contradictory - Emotions (e.g., Love and hate), - Ideas (e.g. being present and absent at the same time, or present in two places simultaneously e.g. in Alexandria and Tanta) It occurs in schizophrenia. (III) Symptoms & Signs of Intellect Talk Memory Intelligence Thinking Attention & Abstraction Perception concentration Judgment & insight Cognition Orientation A- Disorders of talk 1. Stream of talk: The rate of production of words. a) Slow stream: lack of spontaneous talk, delayed response or mutism occurs in some cases of schizophrenia and retarded depression b) Block: Sudden stopping of speech for a while then continue again, occurs in normal (moments of surprise) and in schizophrenia c) Rapid or Pressured stream: Spontaneous talk, rapid response and difficult to interrupt as in mania and accompanied by racing thoughts. 11 Dr.Para Dise 2. Expression of talk: the way of production of words. Lack of association: The talk is not perfectly connected, this is usually in patients with psychosis e.g., schizophrenia. Suppose a patient is telling a story the lack of association of the story could take the following forms: a) Vagueness: Difficulty to find connection among the paragraphs of the story. This could be in normal individual with poor communication skills or in early cases of schizophrenia b) Flights of ideas: Difficulty to find connection between the sentences of the paragraph. c) Clang association: Is a type of flights of idea in which manic patient mentions paragraph with phrases ended by words similar in sound or rhythm (e.g., the car sounds beep, the sea is so deep, the phone is bleep) so every phrase ended by “eep" d) Incoherence: Difficulty to find connection between the words of the sentence this occurs in schizophrenia e) Neologism: Difficulty to find connection between the letters of the word (new language), this occurs in schizophrenia f) Irrelevant answer: When the patient responds by an answer not related to the asked question g) Derailment: When the patient deviates away from the main topic h) Circumstantiality: The patient mentions unnecessary details about the topic 12 Dr.Para Dise B- Disorders of thoughts A. Stream and expression: as in disorders of talk B. Content: 1. Delusions: False fixed beliefs which can’t be corrected by logic and not accepted by persons of the same cultural, religious and social level. Delusions are psychotic symptom that occurs in schizophrenia, bipolar disorders or depression with psychotic features. Types The patient believes that others are against Persecution him and intended to cause harm to him The patient believes that everything in the environment is Reference referring to him. The patient believes that his thoughts are transmitted through Broadcasting mass media The patient believes that he is under influence of external Influence control e.g., he is controlled by satellite signals. Grandeur Patient believes that he is great, having special power or talents. The patient believes that he is poor or will Poverty be losing everything without any rationale. Nihilistic The patient believes he or part of his body does not exist. The patient believes that he is responsible Self-reproach and blames himself for any negative or bad incidents occurring in the environment. Delusions of sin The patient believes that he committed sinful acts. Hypochondriacal The patient believes that he has physical disease. 13 Dr.Para Dise 2. Obsessions: Intrusive thoughts, impulses or images. the patient knows it is meaningless and tries to resist but he fails due to growing feeling of inner tension that relieved by compulsions to perform certain act. Difference between delusions and obsessions Patient fight for it Delusions It has meaning to him don't know that it is a product of his mind Patient fight against it Obsessions know it is meaningless Know it is a product of his mind C- Disorder of perception 1. Hallucination 2. Illusions Perception of non-existed stimulus. False perception of an already It can take any sensory modality. present stimulus. (Auditory, visual, tactile, gustatory, It can affect any sensory modality olfactory) (Auditory, visual, tactile, gustatory Occur in both and olfactory). - Psychiatric disorders (like auditory It can happen to hallucinations in schizophrenia) - Normal individual in certain - Organic disorders (like visual situations e.g., in case of hallucination in drug intoxication states) surprise. Normal hallucinations occur in the - In organic brain disorders like transition zone between sleep and delirium and rarely in wakefulness (hypnagogic & psychotic conditions. hypnopompic hallucinations). 14 Dr.Para Dise D- Disturbance consciousness 1. Conscious: It is the individual who is fully responding to all forms of stimuli (Physical and verbal internal and external) Disturbance of conscious could take the following forms: 1. Drowsiness: delayed but appropriate response to all forms of stimuli 2. Confusion: delayed but inappropriate response to all forms of stimuli. 3. Coma: no response to any form of stimuli. 2. Delirium: A clinical syndrome due to acute brain insult. Characterized by disturbance in: 1. Consciousness: in the form of confusion or drowsiness. 2. Behavior: in the form of agitation and restlessness. 3. Mood: in the form of fear and irritability. 4. Cognition: in the form of disorientation or in-attention. Delirium is caused by: 1. Acute focal brain insult e.g., trauma, infection, ischemia or hemorrhage. 2. Acute systemic diseases e.g., fever, renal, hepatic, cardiac, endocrinal or respiratory diseases. 15 Dr.Para Dise E- Memory disturbance (Registration, retention and recall) 1. Amnesia: 1. For recent events occurs in dementia. 2. For remote events may occur in normal individual and in late-stage dementia. 3. Total amnesia very rare and occurs in hysteria & late dementia. 4. Circumscribed amnesia: it is amnesia for specific period of time and the patient can remember before and after that period this occurs in head trauma and dissociative states. 2. Paramnesia: a) Confabulation: The patient compensates the amnesic gaps by inventing events of his own. This occurs in organic disease e.g., alcoholism. b) Falsification: The patient is not remembering anything so he invents the whole story from his own. This could occur in normal individuals with false testimony and in some psychotic and organic states. 3. Hypermnesia: Sharp memory. This could occur in some normal persons and in mania and delusional disorders. F- Attention: Selective focusing upon certain part of the environment. 1. Impaired attention: Occurs in many psychiatric disorders e.g., organic brain disorders, schizophrenia & depression. 2. Distractibility: Attention to every passing stimulus occur in mania and ADHD. 16 Dr.Para Dise G- Orientation: Ability to realize time, place, persons. It is impaired in organic brain disorders like delirium. H- Intelligence: The ability to benefit from the past experience. It is diminished in cases of intellectual disability. J- Abstraction: It is the ability to make general conclusion from specific example (grasp the meaning standing behind a given situation). It is impaired in schizophrenia and organic brain syndrome. K- Insight and judgment The extent to which the patient can realize the exact nature of his Insight illness and react to it in a proper way. The ability to grasp the meaning of a given situation and hence react Judgment to it in a proper way. 17 Dr.Para Dise Psychiatric interview is the main tool in evaluating patients with mental disorders. It includes: History and Examination (Mental state examination and General examination) History 1) Personal data: 1. Name: Name is important because: Identification of patients facilitates communication and gives a sense of familiarity. Registration of patients is important for future research. A patient may hide his name due to suspiciousness. Some patients may be traumatized by their names. Name may reflect the patient's culture e.g.; certain names are used to prevent children death. 2. Age: Age is important because: Certain disorders are common in certain age groups, e.g., dementia is common in elderly Adjusting drug dose according to age Prognosis differs with age 3. Sex: Sex is important because: Incidence of some mental disorders differs In males: antisocial personality disorder and drug abuse are more common In females: depression and histrionic or borderline personality disorders are more common. Course of disorder differs: - Males are more to commit suicide - Females are more to attempt suicide 18 Dr.Para Dise 4. Residence: Address is important for registration and follow up. It gives an idea about patients' culture and socioeconomic status. 5. Occupation: The current employment state. 6. Marital state: Married, separated, divorced, widow, single. 7. Religion: Muslim, Christian or Jewish. It gives an idea about: - How the patient deals with stress. - How religion shapes the symptoms. - How religion influences treatment. 8. Source of referral: Whether the patient comes by himself or referred by a family member, a work authority, a legal authority or a medical specialist 9. Cause of referral: Which may be: - Personal suffering: depressed mood, obsessions, Insomnia. - Legal responsibility. - Dangerousness: the patient is suicidal or homicidal. - Relief of the family. 10. Type of admission: Voluntary (coming by his will, has insight) Compulsory (coming against his will, has no insight) admission. 11. The informant: Name, age, sex, occupation, relation to the patient and whether reliable or not. 19 Dr.Para Dise Comment ‫ االسم‬ ‫ السن‬ ‫ العنوان‬ ‫ بيشتغل وال أل وبيشتغل اي‬ ‫ متجوز وال أل و عنده أطفال وال أل و عمر أكبر واحد وأصغر واحد‬ ‫ أي اللي جابه المستشفى وجاي بنفسه وال حد جايبه غصب عنه‬ 2) Chief Complaint: Should be in patient’s own words from his point of view States why he or she comes Recorded regardless of how bizarre it is. Information are also gathered from other sources as the family or spouse ‫شكوى العيان األساسية ومتستخدمش مصطلحات طبية في تسجيلها‬ 3) History of present illness: Onset of symptoms Precipitating factors. Course and duration of symptoms Functional impairment Previous treatment: 1. Drug history (type, dose, duration, compliance, side effects, efficacy) 2. Psychotherapy or ECT, previous hospital admission Comment ) ‫ اعمل تحليل لشكوى العيان ( األعراض بدأت امتى و جات مرة واحدة وال بالتدريج‬ ‫ امتى األعراض تزيد وامتى تقل‬ ‫هل بياخد ادوية أو بيعمل جلسات كهربا‬ 20 Dr.Para Dise 4) Past history: Past psychiatric history: previous episodes as in bipolar disorder. Past medical history: fever, head trauma, neurological disorder, hepatic or renal impairment, hypertension or cardiac problems, diabetic or not. ‫هل دخل المستشفى قبل كدا واي سبب دخوله المستشفى‬ ‫هل اتعرض ألي نوبات مشابهة قبل كدا‬ 5) Personal history: 1. Early development: Wanted child or not Pregnancy: Diseases, medication use, trauma Delivery: type, complicated or not, birth injury Milestones of development: crawling date, walking, sphincter control Child diseases: fever, encephalitis, epilepsy Feeding habits: breast-fed, bottle-fed or eating problems. Symptoms of behavior problem: thumb sucking, temper tantrums, head banging, rocking, night terrors, fears, bed wetting or nail biting 2. School history: It gives idea about intelligence, social relation Age of beginning, type of school, attitude toward peers or teachers, interests, progression or school performance Causes of difficulties of academic achievement: - Low intelligence or learning disability - Social problems: no time for study - Physical problems: chronic or recurrent illness - Mental illness: schizophrenia, mania, depression or attention deficit hyperactivity disorder. 21 Dr.Para Dise comment ) ‫ هل كان طفل مرغوب وال أل ( عيل غلطة‬ ‫ نوع الحمل و الرضاعة و هل نموه كان طبيعي وال أل‬ ‫ دخل مدرسة وال أل و نوع المدرسة و مستواه الدراسي وهل كان مشاغب مثال أو بيهرب من المدرسة‬ ‫لو مكملش تعليم تسأل ليه وكان عند كام سنة وقتها‬ 3. Occupational history: Type of job, its requirements, frequent change, degree of satisfaction, conflicts related to work, relations with authorities and peers, reason of job change and salary. Occupational history is an important item due to: 1. Frequent change of jobs within short time may indicate presence of mental disorder 2. Identify the degree of stress and its type (mental or physical) which may cause depression or anxiety 3. Low degree of job satisfaction may predispose depression ‫اسأله بيشتغل وال أل و بيشتغل فين و المرتب مجزي وال أل و شغله كام ساعة في اليوم‬ 4. Sexual history: Onset of puberty: feeling about, development of 2ry sex characters Adolescent sexual activity: dating, masturbation (frequency, attitude, associated feelings, object use) Attitude toward opposite gender Determine any sexual dysfunction: premature ejaculation, lack of desire Sexual preference Current sexual practice: satisfactory or not, frequency, desire 5. Menstrual history: Age of menarche: attitude toward period, regularity, amount, premenstrual tension Age of menopause: feelings toward it. 22 Dr.Para Dise 6. Military history: Dealing with authority Stress of new environment Duration, any problems ‫ حياته في الجيش كانت عامله ازاي‬, ‫دخل الجيش وال أل ودخل امتى و خرج امتى‬ 7. Legal history: Any legal problems ‫اسأله لو ليه أي سوابق جنائية أو اعتداءات جسديه على حد‬ 8. Marital history: Age of patient at marriage Spouse: age, occupation Type of marriage: Love, arranged, forced, business Communication within marriage, sharing problems, pattern of argument Quality and frequency of sexual relations Attitude of partner towards patient illness Children: age, number, relationships between parents and their children Mental disorders increased with: 1. Single, divorced persons 2. Frequent problems within marriage 3. Low level of support toward partner physical or mental problems. Commen t ‫ متجوز وال أل‬ ‫ لو متجوز اسأله اسمها أي و متعلمه وال ال‬ ‫ متجوز صالونات وال عن حب‬ ‫ هل حصل خالفات كبيرة‬ ‫ و مهم تسأل عن سبب الطالق‬, ‫ هل طلق قبل كدا و امتى‬ 23 Dr.Para Dise 9. Alcohol and drug history: Smoking amount and duration Alcohol drinking: Drinking any more or less amount recently Taking drugs of abuse (Smoking index = number of cigarettes daily * years ‫بتدخن وال أل و كام سجارة في اليوم و بقالك كام سنة ( وتحسب‬ ‫ هل بتشرب حشيش أو كحوليات او بتاخد حقن‬, ‫بتتعاطي أي أنواع مخدرات زي الترامادول مثال‬ 6) Personality assessment: From relatives: Social relations: extraverted or introverted, leader or follower Interests: sport, shopping, reading, TV watching, music listening Mood: euthymic, sad, anxious, elated, stable or swinging Character: sensitive, shy, suspicious, impulsive, jealous, dramatizing, rigid Energy: energetic or lazy Comment ‫ عالقته باللي حواليه و هل هو عشري و ال منطوي مع نفسه‬: Relations ‫ أي هي هواياته لو كان ليه هوايات و بيعملها بانتظام وال ال‬: Interests ‫ مز اجة النهاردة عامل از اي و هل دا ثابت معاه طول اليوم وال بيتغير‬: Mood )‫ شخصيته اللي الناس تعرفه بيها عامله از اي (حساس بزيادة مثال أو شكاك‬: Character ‫ شخص نشيط وال كسول‬: Energy 7) Family history: Parents: name, age, occupation, if died (cause of death) Siblings: name, age, occupation, order of siblings Home atmosphere: calm, troublesome Family diseases: physical or mental diseases 24 Dr.Para Dise Comment ‫ هل األب و األم قر ايب‬ ‫ أهله عايشين وال أل و اسم و سن كل واحد ولو حد مات اسأله عن السبب و البيت في مشاكل مثال‬ ‫ اسأله عن اخواته اسمهم وسنهم و تعليمهم‬ ‫ هل في أي امراض عضوية في العيلة زي الضغط و السكر‬ ‫ هل في أي امراض نفسية في العيلة‬ b) Mental state examination General appearance and behavior: State of consciousness: conscious, drowsy, confused, coma. General appearance: Dress or grooming: manic patient may wear bright colors. Personal hygiene: poor personal hygiene in schizophrenic patients, alcoholics. Facial expression: provide information about mood (depressed, anxious, fear) Interview behavior: attitude toward examiner which may be cooperative, uncooperative Motor behavior: observed any motor abnormalities ‫األول هتشوف هو واعي وال ال‬ ‫لبسة نضيف و جاي نضيف و مهتم بنفسه وال مهمل في نضافته الشخصية‬ ‫شوف هو قلقان منك أو خايف مثال و متعاون معاك وال ال‬ ) ‫شوف حركته ( هل بيتحرك من نفسه و هل عنده أي مشاكل في الحركة‬ Language and speech: Stream of talk: whether slow or hurried Expression of talk: loosening of association, incoherence or neologism ‫كالمه سريع وال بطئ و مترابط مع بعضه وال أل‬ ‫صوته عالي وال واطي‬ ‫هل بيتنقل من فكرة لفكرة وال كلمه مظبوط‬ ) ‫بيرد ازاي على اسألتك ( باستفاضة وال على قد السؤال‬ 25 Dr.Para Dise Affect: Comment on: depth, intensity, duration, fluctuations Expression: what feelings appear on patient face Experience: what feelings the patient has within ‫هتشوف تعابير وشه وتسأله اي احساسك دلوقتي‬ Thinking: Comment on: - Stream - Expression - Thought content: delusions, obsession or suicidal ideas ) ‫شوف كالمه ( مغرور وال بيقلل من نفسه‬ ‫لو قال على نفسه المهدي مثال اسأله أي رأيه في الكالم دا‬ ‫هل في أفكار بتجيله وهو عارف انها غلط و مش قادر يمنعها‬ Perception: Ask about hallucinations or illusions ) ‫هل في حاجة بيشوفها أو بيسمعها و اللي حواليه مش مصدقينها ( أي هي الحاجة دي‬ ) ‫لو بيسمع أو بيشوف أشخاص ( اسأله كام شخص وفي بينهم حوار وال أل‬ Orientation: Time: hour, day, month, year Place: hospital, city Person: who are those surround you ‫ عارف مين بيكلمك و بيتعرف على أهله وال ال‬, ‫ انت فين‬, ‫ النهاردة أي والساعة كام تقريبا‬, ‫اسمك أي‬ 26 Dr.Para Dise Memory: Immediate memory: repetition of letters or numbers or words after 5-10 seconds. Short term memory: the ability to recall previous information after 5-10 minutes of distraction Recent memory: what was your breakfast? What did you do yesterday? Long term memory: ask about events happened years ago ‫) و قوله هسألك عليها تاني كمان شوية‬1234( ‫اسأله األول حاجة سهلة وخليه يكررها‬ ‫بعد كدا اسأله على حاجة من زمان مدرسته القديمة مثال‬ ‫وبعدين اسأله أكل أي امبارح‬ ‫و أخيرا اسأله على الحاجة اللي سألته عليها في األول‬ Attention and concentration: It is assessed by: - Repeating the days of the week or the months of the year in a reverse manner - Serial subtraction test: serial subtraction of 7. 100 ‫ من‬7 ‫خليه يقول أيام األسبوع بالعكس أو يطرح‬ General knowledge: Assessed by asking about name of the current president, previous presidents, state capitals.... etc. ) ‫أي معلومات عامة ( مين رئيس مصر الحالي مثال‬ Intelligence: It may be assessed - Clinically during interview - Psychometric tests as: 1. Stanford Binet test 2. Wechsler Intelligence test. Proverb explanation is a test of intelligence ‫بتقيسه عن طريق الحوار أو باختبارت معينه‬ 27 Dr.Para Dise Abstraction: It may be abstract or concrete It is evaluated by: - Testing similarities between: orange and apple, bicycle or airplane - Interpretation of proverbs ‫أي الحاجات المشتركة مثال بين التفاحة و البرتقالة‬ Insight: It may be full, partial or no insight Full insight means: - The patient understands that he is ill - His illness is a psychiatric disorder - He needs a psychiatric treatment - There will be compliance for treatment ‫هل هو مقتنع انه تعبان و عارف ان المرض اللي عنده نفسي‬ ‫ وهيلتزم بالعالج وال أل‬, ‫هل هو عارف انه محتاج عالج‬ Judgement: It is the capacity to evaluate information and to use this knowledge to plan for and deal with life situations. It is tested by asking: - What would you do if you found a stamped addressed envelope in the street? - What would you do if you were in a crowded place and were the first person to discover a fire? ‫اسأله هيتصرف ازاي لو لقى عيل تايه أو حريقة مثال‬ 28 Dr.Para Dise General examination Vital signs Neurological examination Other systems examination Investigations Brain imaging Laboratory investigations Psychometric tests 29 Dr.Para Dise.. ‫تتحفظ زي اسمك‬ Psychiatry Case Taking I- History N Steps Student 3 2 1 0 Dress professionally in white coat 1 Introduce himself to the patient as a medical student Seek permission for the interview Personal data 4 3 2 1 0 Name Age Gender Occupation 2 Residence Marital status Religion Type of admission Informant Complaint 4 3 2 1 0 Current complaint of the patient 3 in the patient own words from the patient from the informant History of the present illness 5 4 3 2 1 0 Analysis of the complaint From the patient From the informant The onset of first deviation from baseline 4 The precipitating factor The course of illness 7 The duration of illness Treatment received Admission to hospital Personal 5 Earlyhistory record 6 4 2 0 School record Work record Sexual record Marital history Military history Habit 30 Dr.Para Dise Premorbid personality 5 4 3 2 1 0 social relations interests 6 premorbid mood character energy Family history 3 2 1 0 Name, age, of parents 7 Siblings Psychiatric disorders in a family member Home atmosphere Total /30 31 Dr.Para Dise II- Mental State Examination N Steps Student 2 1 0 Dress professionally in white coat, introduce himself 1 to the patient as a medical student Seek permission for the examination, explain the procedure to the patient and stand on the right side of the patient General Appearance and behavior 4 3 2 1 0 State of consciousness 2 General appearance Interview behavior Motor behavior Language and Speech 3 2 1 0 Examine a sample of the patient's talk 3 Assess the stream of talk Hurried stream Slow stream Assess the expression of talk Affect 3 2 1 0 Assess emotional expression 4 Assess emotional experience Comment on depth, duration, fluctuation Thought 3 2 1 0 1. Assess thought stream 5 2. Assess thought expression 3. Assess thought content Perception 30303301 2303033 0 1 0 601074 01601 7 Illusions 4 Hallucinations 6 32 Dr.Para Dise Attention: 2 1 0 Serial subtraction test Ask the patient to mention days of the week in 7 inverted order Orientation for time, place and person 3 2 1 0 8 Time Place Person Memory: 4 3 2 1 0 Immediate 9 Short term Recent memory Long term Abstraction: 1 0 Ask the patient to interpret a proverb 10 Insight 2022/ 1 2022/ 0 11 2023 that he is ill or not Ask the patient whether he realizes 2023 and whether he knows that he has a mental illness or not Judgment 1 0 12 Ask the patient what he will do if he discovered an envelope on the ground with an address written and a stamp on it Physical Examination: 1 0 Assess the temperature, pulse, blood pressure and 13 respiratory rate Do neurological examination 30303301 /30 Total 601074 33