History Taking, Mental State Examination and Making a Diagnosis Flashcards
What should be included in a psychiatric history?
Presenting complaint History of presenting complaint Past psychiatric history Past medical history Current and recent medication Social history Family history Personal history (Developmental milestones, Schooling/education, occupational history, relationships, pre-morbid personality)
What could be asked when focusing on past psychiatric history?
Past episodes/ diagnoses/ contacts
Previous treatments (psychological, drug and physical)
Inter-episode functioning
Previous admissions
Attempted suicide/ repeated DSH
Previous detentions under mental health legislation
What particular aspects of past medical history may be relevant in psychiatry?
Developmental problems Head injuries Endocrine abnormalities Liver damage, oesophageal varices, peptic ulcers Vascular risk factors
What should be asked when focusing on alcohol/illicit drug history?
Regular or intermittent Amount Pattern Dependance/ withdrawal symptoms Impact on work, relationships, money, police Screening questionnaire (CAGE)
What should be asked when focusing on forensic history?
“Have you ever been in contact with the police or charged with any crime?”
Offences including sentences
Recidivism
Particular attention to violent or sexual crimes
What aspects of a patient’s appearance should be noted?
Height/build
Clothing (appropriate? bizarre?)
Personal hygiene
Make up, jewellery etc
What aspects of a patient’s behaviour should be noted?
Greeting Non verbal cues Gesturing Abnormal movement (tremor, choreioathetoid movements, posturing, akathesia) Cooperative, rapport
What aspects of a patient’s mood should be noted?
Eye contact
Affect
Mood rating
Psychomotor function (retarded, agitated)
What aspects of a patent’s speech should be noted?
Spontaneity Volume Rate Rhythm Tone Dsyarthria Dysphasia
What aspects of a patient’s abnormal thoughts and beliefs should be noted?
Phobias Obsessions Flight of ideas Formal thought disorder Preoccupations Over valued beliefs Delusional beliefs
What questions should be asked when focusing on suicide/homicide?
Suicidal thoughts Ideation Intent Plans (vague, detailed, specific, already in motion) Homicidal risk
What aspects of a patient’s cognitive function should be noted?
Orientation
Attention/ concentration
Short term memory
Long term memory
