History Taking Flashcards
What is useful to bear in mind when discussing the presenting complaint and its history?
Knowledge of specific disorders required - see other history taking decks for questions to elicit specific symptoms
Use the patients own words when referring back but make sure the patient clarifies their meanings ie ‘describe this “voice”’
Chronology of events is very important to establish a patient narrative
What questions are important when discussing PMH/PPH?
Specific diagnoses given
Outpatient vs inpatient treatment; inpatient voluntary or under section
Hx DSH or suicide attempts
Any medical conditions or treatments for that might affect mental health; hospital admissions
What questions are important when discussing DH?
Current prescription - dose, duration, efficacy, compliance, side effects
Clozapine/ECT asked specifically as may indicate higher risk patient
Illicit drug use - what, source (clean needles?), screening tools ie CAGE, explore dependency if necessary ie impact on life, why are they using, treatments for use
What questions are important when discussing FH?
Occupation of family members
- social class
Mental health problems incl any suicides or attempts
Relationships with family - supportive, abusive, dependent/dependencies
What questions are key in a personal history?
Early childhood - place/circumstances of birth, milestones/development, family atmosphere, behaviour
Education - schools attended, attitudes towards, peers, attendance, qualifications gained
Occupation - detail of jobs so far, reasons for changing
Psychosexual development - orientation, relationships, family attitudes/intrusions, first experiences, DA, children
Present social circumstances - own or rented accommodation, financial problems/debts
What questions are key with a forensic history?
Any troubles with the police?
History of violence - all details, against people or property
Jail time
Remorse/learning
What questions are important to ask about premorbid personality?
When are you well?
Volition - what kind of person would you describe yourself as?
Mood - what’s your usual mood like?
Social - how do you get on with other people?
Reaction patterns to stress - how do you react to stress?
Get collateral Hx if possible too
How do you assess risk?
Harm to others - physical, psychological/emotional; safeguarding of anyone vulnerable
Harm to self - DSH/suicide
Accidental harm to self - dementias, self neglect
Vulnerability to exploitation
Historical and current/active risks; modifiable/non-modifiable
