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Paulo Roberto Silveira
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Sáb, 21 de Novembro de 2009 01:03
Escrito por Paulo Roberto Silveira

 

 

COMO EFETUAR O EXAME PSIQUIATRICO CLINICO

 

Paulo Roberto Silveira

Estado mental e observação psiquiátrica

Identificação

Nome. Nacionalidade. Local de nascimento. Data de Nascimento. Sexo. Cor. Estado civil. Profissão. Religião, Grau de instrução. Endereço. Documento de identidade. Data da internação ou do exame.

 

História da doença atual

Quando começou? Como começou a seqüência de aparecimento de sintomas? Que idéia o paciente faz de sua doença? Como pensa em melhorar? Por que foi internado? Que acha deste fato? Colher no primeiro parágrafo as impressões do paciente e, em um segundo parágrafo, as impressões do(s) acompanhante(s). Lembrar que a verdade subjetiva do paciente é importante em Psiquiatria.

 

História pessoal

Gestação. Parto. Condições ao nascer. Foi amamentado? Criança precoce ou retardada? Dentição. Deambulação. Linguagem. Excreta.

 

—    Sintomas neuróticos na infância. Terror noturno. Sonambulismo. Onicofagia. Tardamudez (gagueira). Enurese noturna. Chupar dedos. Criança-modelo. Situação entre irmãos.

—    Doenças infantis: infecção, convulsões.

 

—    Jogos, brinquedos.

 

—    Escolaridade: começo e evolução. Aptidões especiais e dificuldades. Relações com professores e colegas.

 

—    Trabalho: quando começou a trabalhar? Diferentes empregos em ordem cronológica, regularidade. Por que saiu do emprego? Satisfação no trabalho. Ambições. Circunstâncias econômicas atuais.

 

—    Puberdade: história menstrual (menarca, regularidade, duração e quantidade dos catamênios). Dores. Alterações psíquicas. Última menstruação.

 

—    História sexual: primeiras informações. Masturbação (idade, freqüência e culpa). Homossexualismo. Experiências extramatrimoniais.

 

—    Casamento: namoro e noivado. Idade, ocupação e personalidade do cônjuge. Compatibilidade. Vida sexual. Frigidez e impotência. Medidas anticoncepcionais.

 

—    Filhos: número, saúde, personalidade.

 

—    Hábitos: álcool, fumo e outras drogas.

 

—    História médica: doenças. Operações. Acidentes. Doenças atuais (sintomas, datas, duração). Doenças venéreas.

 

—    Sintomas neurovegetativos: insônia. Taquicardia. Epigastralgias.

 

História familiar

 

Pais juntos ou separados? Época da separação. Idade. Saúde. Causa e data do falecimento. Ocupações e personalidade. Irmãos (quantidade, idade, condições maritais, personalidade, causa do falecimento, saúde). Atmosfera familiar.

Acontecimento importante durante os primeiros anos de vida. Relações dos pais entre si e destes com o paciente. História de doença mental na família.

Exame psíquico

 

Este se compõe de duas partes: entrevista psiquiátrica e súmula psicopatológica.

 

Entrevista psiquiátrica

Atenção: utilizar linguagem coloquial para descrever o que se passou durante a entrevista.

 

Atitude geral – Relação com o examinador. Como responde às perguntas? Quais os gestos e posturas e outras expressões motoras? Grau de atividade (lento? Hesitante? Tenso?). Mostra movimentos e atitudes com um fim evidente? Existem atitudes e movimentos que façam suspeitar de atividade delirante ou alucinatória? Resiste aos movimentos passivos? Mantém atitudes ou obedece a comando? Sono, alimentação. Hábitos de higiene.

Atividade/expressão em palavras – Fala pouco ou muito? Espontaneamente ou apenas responde? Vagarosamente ou rápido? Coerente? Em tom de discurso? Com interrupções, silêncios súbitos, mudanças de tema, palavras estranhas à sintaxe? Ritmo. É aconselhável registrar as próprias palavras do paciente, para ter exemplos de seu pensamento.

Humor – Alegre, triste, irritável, medroso, ansioso, constância de humor?

Atividade delirante – Qual a sua atitude diante das pessoas que o cercam? Mostra-se desconfiado diante delas? Acha que o observam ou o tratam de modo especial? Sente-se perseguido, influenciado por meios naturais, sobrenaturais ou científicos? Riem dele? Admiram-no? Querem matá-lo? Depreciam-no em relação à sua moral, à sua saúde? Possui algum dom especial?

Alucinações e outras desordens da sensopercepção – Auditivas. Visuais. Olfativas. Gustativas. Táteis. Viscerais. O conteúdo dee ser examinado com cuidado. Quando aparecem estas experiências? À noite? Ao amanhecer?

Fenômenos compulsivos – Pensamentos. Impulsos. Atos. São sentidos como vindos da própria mente? Reconhece sua impropriedade? Repete ações como lavar as mãos desnecessariamente?

Orientação – Registro das respostas referentes a seu próprio nome, local onde está, data e idade.

Memória – Comparar dados da anamnese subjetiva e objetiva. Verificar a capacidade de evocação. Examinar a capacidade de fixação para números, palavras e histórias.

Atenção e concentração – É disperso? Tenaz? Para testar a concentração, peça-lhe que enumere os dias da semana e os meses em ordem inversa, ou faça pequenas operações aritméticas.

Conhecimentos gerais - Nomes do presidente e dos governadores. Capitais dos grandes estados do Brasil. Distância entre Rio e São Paulo, etc.

Inteligência – Avaliar de acordo com os dados biográficos e a escolaridade. Utilizar pequenos testes especialmente para os analfabetos.

Noção do estado mórbido e julgamento – Qual a atitude em relação a seu estado? Acha que sua “doença mental ou nervosa” necessita de tratamento? Qual a atitude em relação a problemas domésticos? Financeiros? Sociais? Seu julgamento é bom? Que pensa fazer quando deixar o hospital?

 

Súmula psicopatológica

Atenção: utilizar terminologia exclusivamente técnica. Aparência. Atitude. Orientação (tempo, espaço pessoal). Atenção e concentração. Sensopercepção (ilusão, alucinação). Memória. Pensamento (forma, conteúdo, curso). Idéias delirantes. Afetividade. Vontade e ação. Psicomotilidade.

Exame somático – Peso. Altura. Temperatura. Pele. Pulso. Pressão arterial. Marcha. Motilidade. Tremor das pálpebras. Língua e dedos. Reflexos patelares. Pupilas (forma e dimensões). Reflexo fotomotor, acomodação. Palavra. Testes de disartria. Respiração. Ritmo cardíaco. Atenção especial para um exame neurológico sumário.

 

Exame da constituição

Classificação de Krestschmer (picnicos leptossomáticos, atléticos, dismórficos).

Exames médicos complementares

 

Laboratoriais (sorologia para lues, liquor, hemograma, glicose, uréia no sangue, etc). Eletroencefalograma (EEG). Fundo do olho. Tomografia computadorizada. Teste de supressão de dexametasona, etc.

 

Exames psicológicos suplementares

 

Testes de inteligência, personalidade, etc.

 

Planos do diagnóstico

 

O – Motivo do exame

A – História da doença atual

B – Historia pessoal

C – História familiar

D – Exame psiquiátrico

E – Exame somático

F – Exame da constituição

G – Exames médicos complementares

H – Exames psicológicos suplementares

 

 

Reunião dos dados para o diagnóstico


 

Primeiro plano      Achado psicopatológico       Achado               Achado somático      Achado médico-psicológico

(D+A+B+C)                           constitucional                                                      (H)

(F+G)                            (E+G)

Segundo plano      Síndrome                             Personalidade                         Constelação etiológica

pré-mórbida                            (A+B+C+E+F+G)

(C+B+F+H)

Terceiro plano                                                        Diagnóstico


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O(A) escritor(a) Paulo Roberto Silveira escreve para o Canto do Escritor desde Seg, 26 de Outubro de 2009.

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