History in Psychiatric Patients

A. The history of psychiatry is very important to be asked in the first step to doing history to patients who have psychiatric.

A. The history of psychiatry is very important to be asked in the first step to doing history to patients who have psychiatric disorders . Important things that should be asked :

1 . The identity of the patient such as name , address , age , and occupation .

2 . The main complaint of patients , the main thing that makes dating a patient to see a doctor . In some severe cases, there are times when we can not ask the patient because the patient has been in a state of severe psychiatric disorders , for that we can also ask it to her family .

3 . After that ask how the disease originated , how the beginnings of a psychiatric disorder that occurs , since when , and how sustainability , is meaningful because most psychiatric illnesses experienced several phases before it becomes more severe .

4 . Past history , whether the patient had experienced a disease that can lead to psychiatric disorders such as high fever , history of head trauma , Parkinson’s consuming drugs , anti-hypertensive drugs and kotikosteroid in the long term .

5 . Include a personal history of the patient’s birth history , whether or not he quite the month , or the process of being born through normal Caesar , and if there is a problem when he was in the womb . If the patient is married , ask about marriage . The bottom line in this segment we should explore the patient’s personal .

6 . Family history , ask if there is a family in mentally ill or not .

B. Mental status

1 . Appearance when the patient arrives , can give the appearance of a characteristic in some psychiatric diseases , for example in patients with mania usually they dress and exaggerated dress does not fit with the place. For example, they would like the doctor to the wedding .

2 . How to talk , watch the patient while talking . Usually in depressed patients tend to be closed and their members less information , whereas in patients with mania , they talk constantly relentless .

3 . Mood or mood

4 . Thoughts such as how the patient ’s attention , memory power , if he can take a stand , and how to speak .

5 . Perception , ask if the patient feels there is a whisper , or see something that is not seen by a doctor to determine if patients experience hallucinations .

6 . Sensorium where patients often feel tingling

Psychodynamic formulation is a defense mechanism that is performed by the patient . Such denial ( deny ) , when he will blame blame others, use others to achieve their goals .

Clinical Interview is the way in which the examiner in exploring information to the patient so that the patient would tell the doctor freely . This can be achieved by causing proximity ( rapport ) , confidence (trust ) , assurance ( reassurance ) , and providing a positive emotional response .

In addressing and dealing with patients who have psychiatric disorders need special way . we have to perform some steps, namely :

    Reflection , ie, when the patient tells the things that made ??him depressed , we can give it the support that it really was not just him who experienced it , there are many others who are experiencing the same thing even more severe . In this way the patient will not feel alone .
    Silence , namely during the patient’s story, try to be quiet and listen even when she cries try to be quiet until the patient finished .
    Confrontasi , giving patients more encouraging statement . For example, when a patient told me that he often stopped work because they feel bored , the doctor said : ” If the mother is more likely to be patient , the result could be better ” .
    Classification , whereby after a patient told me , explained the problem , the doctor tries to classify the subject matter
    After grouping constraint faced by the patient , the examiner attempted to interpret or assess problems.
    Summation is to make conclusions on the constraint faced by the patient .
    Explanation , the examiner explained the start of the main issues to how to resolve the problem of the patient. Starting from the treatment plan to solving the problem

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