Psychiatry 精神病学 Wang Keqin Jining Medical College Jining Medical Colleg
Chapter 2.Psychiatric assessment 1.Format of a psychiatric history 2.The Mental Status Examination 3.Making sense of psychiatric histories 4.The assessment ofrisk ■5.Investigations Jining Medical College
1.Format of a psychiatric history (1).Identifying Information (2).Chief complaint (CC) ■（③）.History of present illness (HPD (4).Past Psychiatric History ry th ■（⑤）.Past Medical History ■（⑥）.Family history ■(7.Personal history Jining Medical College
Outline of Psychiatric History 1.Identifying data ll.Chief complaint Ill.History of present illness A.Onset B.Precipitating factors IV.Past illnesses A.Psychiatric B.Medical C.Alcohol and other substance history V.Family history VI.Personal history (anamnesis) A.Prenatal and perinatal B.Early childhood(Birth through age 3) C.Middle childhood (ages 3-11) D.Late childhood (puberty through adolescence) E.Adulthood 1.Occupational history 2.Marital and relationship history 3.Military history 4.Educational history 5.Religion 6.Social activity 7.Current living situation 8.Legal history F.Sexual history G.Fantasies and dreams H.Values Copyight Woter Kue He Lppincott WWn
(1).Identifying Information Name,address,phone number,and e-mail address ■Insurance Age,gender,marital status,occupation,children, ethnicity,and religion For children and adolescents:primary custodians, school,and grade Primary care physician Psychiatrist,allied mental health providers ■Referral source Sources of information ■Reliability Jining Medical College
(2).Chief complaint (CC) Reason for consultation; CHIEF the reason is usually a COMPLAINT direct quote from the Sleep and Sexual patient or family i、Food and Drinks General Physical members Mental Emotional ■Main symptoms and Never Well Since duration Delusions CORE bE工UsON Jining Medical Colleg
(3).History of present illness (HPD) ■Onset Perceived precipitants ■Signs and symptoms ■Course and duration Treatments:professional and personal Effects on personal,social,and occupational or academic function Co-morbid psychiatric or medical disorders Psychosocial stressors:personal (psychological, medical),family,friends,work/school,legal,housing, and financial Jining Medical College
(4).Past Psychiatric History Psychiatric Disorders Symptoms,course,duration,and treatment (inpatient or outpatient) Previous Episodes of the Other Problem(s) Symptoms,course,duration,and treatment (inpatient or outpatient) Jining Medical College
(5).Past Medical History Medical problems:past and current Surgical problems:past and current ■Accidents ■Allergies Current medications:prescribed and over-the-counter medications Pregnancy history:births,miscarriages,and abortions Sexual history:birth control,safe sex practices,and history of,and screening for,sexually transmitted diseases Current alcohol or illicit-drug usage. Jining Medical College
(6) Family history ■Family psychiatric Standardized Pedigree Symbols and Relationships history ▣Male 0T0 Couple OFemale ■Family medical y◇Sex unspecified with offspring) history ☐Proband Adopted in ■ ●Affected 0T0 Adopted out ①Carrier(autosomal) o ⊙Carrier (x-linked) 白ù Monozygotic twins ☑Deceased db Dizygotic twins ☐Divorced 白？▣ Zygosity unknown ☐Consanguinous mating Jiing MedcarConege