The assessment includes the general medical and psychiatric history and the collection of mental status. (See also the American Psychiatric Association’s Psychiatric Evaluation of Adults Quick Reference Guide.) History The doctor must determine whether the patient can even provide information about his medical history, d. h. whether the patient some initial questions willingly and conclusive answers. If that is not the case, the information is collected from family, caregivers or other additional sources (eg. As the police). Even if a patient is communicative, close to him family members, friends or Individualf├╝rsorger might be able to contribute information that has skipped the patient. The receipt of additional information that the doctor has not asked, does not constitute a breach of faith with the patient Earlier psychiatric assessments, treatments and the degree of adherence to former treatments are reviewed. related files are as soon as possible to request for release of medical records. the doctor leading the medical history quickly and indifferent or provides preferred closed questions (by z. B. follow a strict systematic review scheme), the patient keeps you better not disclose relevant information. It is better to ask open-ended questions about the history of the present illness and let the patient tell in their own words; which is similar to time-consuming and it allows to describe the disease related social circumstances and to show emotional reactions to patients. In the medical history should first be explored what the need (or desire) causes a psychiatric assessment has (z. B. unwanted or unpleasant thoughts, unwanted behavior) affect patients or and how much the symptoms present his social, professional and interpersonal interfere function. Then, the interviewer is trying to gain a broader view of the patient’s personality by-current and past-significant life events and the reactions of the patient discusses the fact (s. Areas to be covered in the psychiatric Initial Coverage). The psychiatric, medical, social and developmental history are also evaluated. A review of organ systems to other symptoms that are not described in the psychiatric history is important. Only to focus on the existing symptoms can lead to overlook either psychiatric or medical comorbidities. Areas to be covered in the psychiatric Initial Coverage area elements Psychiatric history Known diagnoses Previous treatments, incl. Medicines and hospitalization medical history known diseases and chronic disorders Emergent physical symptoms Current medications and treatments social history education and career in training (eg. B. school grades, difficulty in school for u create) marital status, incl. quality and stability of marriage or marriages or Professional of partner relations career, incl. stability and efficiency at work delinquency, incl. arrests and detentions housing conditions (eg. B. alone, in the family, in the home or homeless shelter, on the street) pattern of social life (eg. As quality and frequency of interaction with friends and family) Sanitary background in the family known diagnoses, incl. Mental disorders reaction the usual vicissitudes of life divorce, job loss, death of friends and family members, illness, other failures, setbacks and losses behavior when Auotfahren development history family composition and atmosphere during childhood behavior during the Au sbildung handling different family and social roles Sexual adaptation and experiences daily behavior or abuse of alcohol, drugs / medicines and tobacco potential to themselves or others to violate suicidal ideations, plans and intentions Previous suicide attempts and means used intention to harm the resulting personality profile can adaptively personality traits point (eg. show as resilience, of duty) and (to those that indicate a poor match z. B. self-absorption, dependence, low frustration tolerance), and the Copping mechanisms used. The medical history can (unwanted or disturbing thoughts or impulses), compulsions reveal obsessions (urge to commit irrational or apparently useless acts) or delusions (fixed false beliefs) and determine whether the distress rather (in physical symptoms such. As head expresses, abdominal pain), (in psychological symptoms such as phobic behavior, depression) or (for example in social behavior retreat, rebelliousness) -… The patient should be asked about his attitude to psychiatric treatments, incl. Medication and psychotherapy as well, so that this information can be considered in the treatment plan. The interviewer should determine whether a physical illness or its treatment causes a mental disorder or it worsens (medical evaluation of a patient with mental symptoms). About the direct effects (eg., Symptoms, incl. Mental), many physical diseases cause enormous stress, and there are coping strategies required to withstand the disease-related pressure. Many patients with severe physical diseases have an adjustment disorder on to a certain degree; Patients with underlying mental disorder may be unstable. to observe the patient during the medical history can provide clues to mental disorders or physical illness. Thus, the body language attitudes and feelings can visualize that denies the patient. Wriggles the patient z. B. and he runs back and forth, though he denies any fear? the patient seems to be sad, although he denies depressive feelings? The overall appearance can also provide clues. If the patient z. B. clean, and he pays attention to his appearance? Are a trembling or droopy facial features to recognize? Survey of mental status in the collection of mental status are evaluated on the basis of observations and questions targeted various functions; these include language, emotional expression, thought and perception, and cognitive functions. To determine certain components of the survey in mental status are brief standardized questionnaires available, incl. Special questionnaires for the assessment of orientation and memory. Such standardized assessments can help to identify the main symptoms, and provide a basis for the detection of the response to treatment. However, screening tools can not replace a more comprehensive and detailed survey of mental status (examination of mental status). The general appearance should be tested for nonverbal cues to underlying disorders. The appearance of the patient can help in assessing whether they are unable to care for themselves (they appear z. B. malnourished, disheveled and dressed inappropriately for the weather or have a significant body odor) if they are not willing or able must be complied with social norms (they wear z. B. socially unangemesse clothing), or whether they operate drug abuse or self-harm attempts (they exude such. as alcohol smell, have scars that indicate intravenous drug abuse or self-harm). The language can be judged based on spontaneity, syntax, speed and volume. A patient with depression may speak more slowly and quietly, a patient with mania rather fast and loud. Abnormalities such as dysarthria and aphasia may have a physical cause mental changes such as a head injury, a stroke, a brain tumor or multiple sclerosis show. The emotional expression can be assessed by asking the patient to describe their feelings. Tone, posture, gestures and facial expressions of the patient must be considered. Mood (of patients reported emotions) and affect (quoted from a leader emotional state) should be assessed. Discrepancies between mood and emotion must be observed. Thinking and perception can judge yourself by what is being communicated, care is taken not only, but also of how it is communicated. Abnormal contents can be as delusions (fixed false beliefs), delusional self-reference (presentation of patients that everyday events have a special meaning for him, happened because of him or against him), or (as obsessions lasting ideas, feelings, impulses and worries) express. The doctor can determine if the thought processes linked together and appear to be targeted and whether the thoughts transitions are logical. Psychotic or manic patients may suffer from disorganized thinking or abrupt flight of ideas. Among the cognitive function of the degree of the patient, attention or concentration alertness, orientation towards persons, place and time, memory and memory, abstract thinking, understanding and discernment belong. Cognitive abnormalities are found most often in delirium or dementia or substance dependence or withdrawal, but they can also occur in depression.


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