History taking Flashcards
Psychiatric history taking subsections
- Presenting complaint
- History of presenting complaint
- Previous psychiatric history
- Previous medical history
- Medication history and allergies
- Family history
- Social history
- Forensic history
- Personal history
- Pre-morbid personality
- Mental state examination
Presenting complaint questions
Why have you come to see me today?
Previous psychiatric history
Record previous episodes of illness, their treatment and duration.
Particularly note any episodes requiring use of the mental health act.
Family history
Relationships with parents/siblings
Has anyone in the family suffered from problems like you’re having?
Has anyone in the family had a mental illness?
Social history
Accommodation? Who lives with them?
Work? Financial support?
Family/friends?
Interests and activities?
Drugs and alcohol?
Forensic history
Have you ever been in trouble with the police?
Charge and outcome?
Premorbid personality
How would you describe your normal self?
Personal history
I would like to know a little bit about your early life?
- Early development
- As far as you know where there any problems with your mother’s pregnancy with you?
- Did you meet all your developmental milestones as a child?
- Childhood experiences
- How would you describe your childhood?
- We ask everyone this, but have you ever experienced physical, mental or sexual abuse?
- How did you find school? Did you make friends easily?
- Educational attainment
- When did you leave school? What qualifications did you have?
- Occupational history
- Relationship and maritial history
- Sexual history
Aspects of mental state examination
- Appearance and behaviour
- Speech
- Mood
- Thought-form
- Thought-content
- Suicidal thoughts
- Perception
- Insight
- Cognitive function
Appearance
- Personal hygeine
- Clothing
- Weight
- Objects
Behaviour
- Engagement and rapport
- Eye contact
- Facial expression
- Body language - threatening or withdrawn?
- Psychomotor abnormalities - retardation or fidgeting?
- Abnormal movements or postures
Speech
- Speed of speech - pressure of speech, slow speech
- Quantity of speech - excessive or minimal
- Tone of speech - monotonous (depression, schizophrenia), tremulous (anxiety)
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What is the difference between affect and mood?
Affect is what you see, mood is what the patient tells you
