History and Examination Flashcards
Questions about Presenting Complaint?
-Duration & onset
-Progression of symptoms
-Episodic or continual
-Better or worse?
-Precipitating factors
-Anything like this before
-Assoc symptoms
-Psychiatric symptoms: psychosis, anxiety, depression, elevation of mood
-Impact on daily activities of living
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Risk assessment?
- Always screen for DSH, suicide
- How do you feel about your future?
- Do you think life is worth living
- Many people who are experiencing feelings like this have thought about DSH or suicide. Have you ever thought about this?
- Ever thought about harming anyone else?
Past psychiatric history?
- Ever been diagnosed with mental health illness
- Treatments given? Did they work
- Inpatient or outpatient?
- Did you have a choice about whether you got those treatments
PMH?
- Any other medical problems
- Screen for: chronic health conditions (diabetes, HT), head injury, epilepsy, thyroid disease, stroke, dementia and parkinsons
- Physical health now: Wt changes, fatigue, memory loss, attention, chest pain, bowel/bladder, numbness/weakness?
PMH?
- Any other medical problems
- Screen for: chronic health conditions (diabetes, HT), head injury, epilepsy, thyroid disease, stroke, dementia and parkinsons
- Physical health now: Wt changes, fatigue, memory loss, attention, chest pain, bowel/bladder, numbness/weakness?
Family History?
- Who in immediate family (age, occupation, health
- How is family relationships
- Able to rely on them for support, if not who?
- Anyone in family experienced similiar?
- History of mental illness
- Any physical illness run in family
Personal history?
-Ask about childhood, job “Only answer them if you feel comfortable because I understand it can be quite difficult to speak about” explain you are just trying to get the full understanding of who they are as a person
-Birth/development/childhood
-Education
-Occupation
-Psychosexual
-Relationships
-Traumatic events
-Pre morbid personality
-Forensic history
-Social history
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Questions about birth/development/childhood?
- Mum had any problems during pregnancy
- Born early/late?
- Walked and talked at the right age?
- Anyone having concerns and seen a professional about your development
- Health problems as a child
- Any behaviours from childhood that stood out: bed wetting, tantrums, sleep walking?
- Describe childhood
- Events from childhood that could be affecting you? (bereavement, trauma, abuse, neglect, divorce)
Education questions?
- Did you got to school in this area
- What age did you leave school
- If early, why?
- Qualifications?
- Enjoy school?
- Many friends? Clubs?
- How would you describe your behaviour at school, did you ever skip?
- What did you go on to do post school
Occupation questions?
- Job just now?
- If yes: what, when did they start, enjoy? Sustain lifestyle?, past jobs?
- If no: Previous jobs, when was last job?, how long for?, when leave, struggle wth job?, benefits?
Psychosexual questions?
- Wat age you went through puberty
- Sexual orientation
- First sexual encounter
- Any difficulties with sexual relationships?
- Experienced sexual abuse or non-consensual sex?
Relationship questions?
- Currently in a relationship?
- Gender, age, occupation, length, type of relationships
- How is relationship
- If single: when was last, when did it end, why did it end?
- Do you struggle to maintain relationships
- Children: age, sex, relationship and health?
Traumatic events questions?
Have they had any that they think may still affect you
Pre-morbid personality questions?
- How would you have described your personality before you started feeling the way you do
- How would your friends have described your personality
- Were you a sociable person, what did you enjoy doing?
- Are you a part of any groups or religions
- How did you manage stressful events
Forensic history questions?
- Have you ever been in trouble with police
- When and why?
- Did this lead to a conviction
- Have you spent time in jail
- Do you have any pending charges
