CLINICAL EXAMINATION IN PATIENTS psychiatric INTRODUCTION Diagnosis of psychiatric patients have some differences with the patient's diagnosis of physical disorders. Although there are a lot of progress in various fields such as neuroimaging, molecular biology and genetics, knowledge about the cause of the psychiatric is still not perfect. The difference between the diagnosis of psychiatric disorders with physical disorders disease is absence of a clear external criterion. Evaluation of patients with psychiatric disorders consists of 2 parts: 1. Psychiatric history (eg, family medical psychiatric), including in this case the patient's description of symptoms - symptoms that happened, a history of psychiatric patients and their families and their previous treatment, current medical history and previous. This history can be done with auto or alloanamnesa. 2. Mental status examination to assess the emotional and cognitive functions of patients at the time of the interview. HISTORY psychiatric History illness / mental disorder and a history of a patient's life as told by the patients from their own perspective. Often required information from other sources (parents or spouse). Psychiatric history is a record of the patient's life that allows the doctor of psychiatry to understand who the patient, where patients come and go where the possibility of future patients. History is the story of the life of a patient who told doctors in the words of the patient and the patient's own point of view. Obtaining a complete history of a patient and if necessary, from the known sources is essential to make the proper diagnosis and treatment plan is effective and specific. Psychiatric history is somewhat different from that explored the history of medicine and surgery, in addition to digging and concrete data about the actual chronology of the formation and history of psychiatric symptoms and past medical, psychiatric doctors are also trying to get that elusive picture of the history of the personality characteristics of individual patients, including the power and the weakness of the patient. The most important technique in obtaining the psychiatric history is to let patients tell their own with their own words to let them feel the most important. A number of standard formats can be accepted for psychiatric history, one of these formats in the table below. Historical Outline of psychiatric I. Identification Data II. Main complaint III. Disturbance History Now 1. Onset 2. Factor triggers IV. Previous Disturbance History A. Psychiatric B. Medical C. Substances and Alcohol Use V. Family History VI. Personal CVs (anamnesis) A. Prenatal and Perinatal B. Childhood Home (up to age 3 years) C. Childhood Ages (ages 3 to 11 years) D. Childhood End (puberty - teens) E. Adult period 1. Employment History 2. History Marriage / relationship 3. Military History 4. Education History 5. Religious 6. Social Activities 7. Living Situation Now 8. Legal History F. Psychosexual history G. Dream and Fantasy H. Value Life Identification Data Identification of demographic data provides a brief summary of the patient's name, age, marital status, gender, occupation, language, ethnic background and religion and the state as far as related to current life. Psychiatric physician must state whether the patient comes to their own desires, referred to by others or taken by someone else. Identification of data is a tool to know briefly about the possibility the patient characteristics that may affect critical diagnosis, prognosis, treatment and compliance. Example: John Jones is a man's 25-yearold Catholic who is not married, currently unemployed and homeless, living place of public accommodation or on the street. The interview is now done in the emergency room with patients in cramped conditions on the motion and all four members of staff attended the clinic and 2 police officers 1. This incident was a visit to the Tn 10. John in the last 1 year. Sources of information about Tn. John from the patient himself and police officers who took him to the ER. Police officers are often seen Tn. John street and recognized him. Main complaint The main complaint is the word - the patient's own words stating why he had come or were brought in to get help. The explanation depends on how the patient is not disrupted or irrelevant complaint, still must be recorded verbatim in the main complaint. If a patient comes in can not communicate (silence), others who came with him can be a source of information, more people are expected to provide information according to their own version of events on the history of present illness. Example: "I feel very depressed and thought about killing myself." "Every vehicle in front of my house has a number of police who sent me a secret message about a plan to kill the president." "No one hurt in me; she is crazy." "Patients in a state of silence." Disease History Now Part of this psychiatric history can provide a complete picture and chronological of events that led to the situation or the moment a patient like this. The development of symptoms should be described and summarized in a structured and systematic. Symptoms that do not seem too must be described in detail in the history of present illness, allowing doctors to make an accurate diagnosis. Patients are generally organized chronologically able to convey history with both disorders, but a patient who is not organized more difficult to do the interview because the patient is difficult to tell a chronological disorders so that physicians can contact other informants, such as family members and friends that more can be useful in helping to clarify the story patients. The information needed to determine the history of present illness, among others: Complete and chronological description of events that led to the patient like this. Onset, the precipitation factor. Reasons for treatment now. Environmental factors before the onset of the patient or changes in behavior occur. Personality background. The development of symptoms should be described and summarized in a structured and systematic. The impact of disruption to the patient's life. Nature dysfunction. Symptoms psikofisiologis The link between physical symptoms and psychological. Formerly Disease History This section is a transition from the current history of the disease and the patient's personal history. Episodes of psychiatric or medical illness that should be described, special attention should be given to the first episode that marks the onset of the disease, because it often can provide important data about the event triggers, diagnostic possibilities, and the ability to overcome interference. Causes, complications and treatment of every disease and illness effects on patients should be recorded. Specific questions about psychosomatic disorders should be asked in detail and recorded. All patients should be asked about the possibility of the use of addictive substances, alcohol and other substances, including details of the number and frequency of use. Many medical conditions and treatments can cause psychiatric symptoms and with no previous medical history of support can be diagnosed as psychiatric disorders, eg hypothyroidism and Addison's disease may manifest with depression. Family History Family history should give a personality and intelligence of people who live with the patient since the patient's childhood until now. Kelaianan history of psychiatry, treatment, and achieved one of the patient's family angotta should be listed in detail in this section. The doctor must determine that family attitudes associated with the patient's illness. Some questions that need to be asked: • Is there a history of addictive substances, alcohol and other violent or antisocial behavior in the family? • Does the patient feel supported family members, or indifferent hard? • How patient attitudes toward parents and siblings? • Asking the patient mentioned his family members, who called in advance by the patient? Who is not mentioned? Personal History Patient's personal history is usually divided into childhood, youth, and adults. Various emotions associated with the period of life (stress or conflict) should be recorded. Prenatal and perinatal history • Is the birth of the patient wants or planned? • Are there problems in pregnancy and childbirth? • Are there defects or injury at birth? • How emotionally and physically when the patient's mother was born? • Does the patient's mother using alcohol or other substances during pregnancy? Childhood (from birth to age 3 years) Quality of mother-child interaction during feeding and toilet training is important. Various disturbances in sleep patterns, episodes of banging your head and shake your body can give an indication of possible inappropriate relationship between mother and child. Some things to note: • Are there medical or psychiatric illness in the elderly that may affect the child's parent interaction? • Does the patient demonstrate separation anxiety problems or worries about excessive foreign person during the early period? • Does the child was shy, could not silence / overactive, withdrawn, love to learn, love to travel, fear, athletic, friendly? • Interest in children for active and passive role in the physical game should also be noted. • The habit of playing children like to play alone or with friends or do not play it should be noted, too. • Are there other people other than mothers who care for these children. • Relationships with relatives • Your child's ability to concentrate, deal with frustration, and delay the desire / satisfaction. Eating and drinking habits: drinking milk or milk bottles, eating disorders. Early development: walking, talking, teeth growth, language development, motor development, a sign of unmet needs, sleep patterns, object decision, fear of strangers, deviation maternal separation anxiety. Toilet training: age, parents' attitudes, behaviors about this. Symptoms of problem behaviors: thumb sucking, temper, smashing his head, wetting or defecation during sleep, biting fingers, excessive masturbation. Personality as the children: shy, can not rest, overactive, withdrawn, persistent, happy out, timidly, athletic, friendly, game patterns. Period mid children (3-11 years) In this section a few things to note is the identification of gender, type of punishment used in the home and who enforce discipline and to influence the formation of the conscience of the patient. Ask the school early experiences, particularly how patients tolerate the separation from her mother. The doctor must know the data on the number and familiarity of patients with their peers. Is the child able to work with their peers, to be fair, understand and abide by the rules, and develop a conscience? Consider a history lesson, learning disorders, development of intellectual and motor skills. Notice also the presence or absence Impulsivitas, aggressiveness, passive-active, shy, anti-social. The existence of a dream night, phobias, bedwetting, the desire to play with fire, cruelty to animals, and excessive masturbation should also be explored. Childhood end (puberty through adolescence) Doctors should try to determine the value of social groups of patients and who the idealized by the patient. At this time the child has begun to develop an independent attitude of the parents with children through relationships with peers or in a group. This information is important to know how to view a patient with himself. Social relations Attitudes toward siblings, playmates, the number and intimacy with friends, leaders or followers, social popularity, an idealized figure, pattern or pasifitas aggression, anxiety, antisocial behavior. School History How far the progress of patients, with school adjustment, relationships with teachers, subjects of interest and preferred, ability or a particular talent, extracurricular activities, sports. Cognitive and motor development Learn to read, motor skills and other intellectual property, minimal brain dysfunction, learning disabilities and how to overcome them. Emotional and physical problems Scary night dreams, phobias, masturbation, wet, run away, violations, smoking, use of alcohol or drugs, anorexia, bulimia, weight problems, feelings of inferiority, depression, ideas or attempt suicide. Child sexuality • Curiosity early, infantile masturbation, sex games. • Obtaining sexual knowledge, attitudes of parents toward sex, the sexual abuse. • The onset of puberty, the feeling about it, kind of preparation, feelings about menstruation, the development of secondary sex characteristics. • adolescent sexual activity, dating, masturbation, wet dreams, and his attitude toward it. • Attitudes toward the opposite sex: fear, shame, aggressive, seductive, sexual conquests, anxiety. • Sexual orientation: homosexual experience with heterosexual and homosexual, gender identity issues, self-esteem. Adult period Employment history The interviewer must explore the patient's feelings about his current job and do the job (with the leaders, coworkers, and subordinates) and describes the history of work. History of marriage and friendship History of marriage or long-term relationships should provide a description of the development of relationships, including patient age at the beginning of a long-term relationships, issues approval or disapproval, money, housing difficulties, the role of in-laws and other family members, and attitudes in raising children. Some other things that need to be asked such as: • Is the patient currently is in the long-term relationship? • Does the patient have the ability or the courage to approach the opposite sex that he liked? • How the quality of patient sexual relationships? Satisfactory or not? • How do patients view their partner? • How do patients describe it in positive and negative qualities? Military History Did the patient ever seen a state of war or suffer an injury? Does the patient ever being disciplined for a period of devotion? Education History This information can provide clues about the social background, and the patient's cultural, intelligence, motivation, and every obstacle in the achievement, for example, patients with low economic backgrounds do not have a great opportunity to feel higher education. What level of education or has achieved the highest graduation? Does the patient likes to learn, and how the level of academic achievement? What is the attitude of patients toward academic achievement? Bagaiamana patient attitudes toward academic success? Religious Doctors have described the religious background of both parents and details of the religious instruction of patients. Does attitude toward religious family tight or loose? Does the patient have a strong religious associations and if there is whether it affects the patient's life? What agamaya view of suicide? Social activities Doctors have described the social life of patients and the nature of friendship, with an emphasis on depth, time and quality of relationship with their surroundings. Current living situation Doctors should ask patients describe where he lives, the number of rooms, number of family members, and the composition of the bed. The doctor should ask about how dirumahi privacy issues, with special emphasis nudity parents and siblings and bathroom arrangement. Doctors also need to know the family finances and the economy, and how patterns of child care at home. Legal history Some things to be asked by the doctor: • Did you ever been arrested / in prison? Ever, how many times? • Is never experienced probation? • How pendangannya against the law? • Released on bail? • History of assault / violence? Assault to whom? Wear? Psychosexual history Some things to be known as: • Knowledge of sex? Where to obtain information about sex? • Attitudes of parents • The onset of puberty, feelings about sex? • The development of sexual identity and orientation? • Attitudes toward sex (like, scared, like bragging, aggressive) • Sexual Problem • Is sexually abused? • Parafilia • promiscuity • sexual activity? • Sexual intercourse outside of marriage • Diseases sex (AIDS, etc.) • Changes in sex lately? • How does it feel / response of patients in the sexual cycle phase 4: 1. Desire: sexual fantasies, when occurred, who object, who began sex and how. 2. Excitement: whether there are difficulties in sexual awakening, and the relationship during foreplay before orgasm. 3. Orgasm: Sexual climax with the release of sexual tension and rhythmic contraction of perineal muscles and the pelvic reproductive organs. 4. Resolution: what happens after sex is complete. (example: frustration, revival continues). Dreams, fantasies and values The doctor must know the content of dreams, fantasies and values - values on social and moral upheld by the patient. Through it - it can be known to the patient's feelings and emotions. Some things that can be asked such as: • Does the patient have had a bad dream? What is the theme of the dream? • Ability to describe the last dream? • Possible meaning of dreams? • Fantasies about the future? A favorite fantasy / often? • What is essentially a fantasy come true? • enables tell between fantasy and reality? • personal values about the moral, social, sex, children, parents, culture, employment, it is wrong and right?
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