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  • Ms. Meril Manuel Lecturer VINE
  • IntroductIon Psychiatry History Taking :  It is the record of the Patient‘s life It allows to understand o who the patient is o where the patient has come from o where the patient is likely to go in the future.
  • Definition The psychiatry history is the record of the patient’s life; it allows a psychiatrist to understand who the patient is ,where the patient has come from ,and where the patient is likely to go in the future. View slide
  • IMPORTANCE • Obtaining a comprehensive history from a patient and if necessary from, from informed sources are essential to make a correct diagnosis and formulating a specific and effective treatment plan. View slide
  • PurPose :- To describe adaptive and maladaptive behavior. To formulate priorities. To identify problems. To predict probable responses to potential interventions. To analyze the client’s perceptions. Helps to develop nursing care plan.
  • BASIC PRINCIPLES OF HISTORY TAKING • Introduce yourself • Explain the purpose and approx how long it will take • Ask Open Ended Questions • Allow the patient to Explain Things In his/her Own Words
  • BASIC PRINCIPLES OF HISTORY TAKING •Encourage the patient to Elaborate and explain • Avoid Interrupting • Guide the Interview As Necessary • Avoid Asking “Why?” Questions • Listen and Observe For Cues • You might need an informant
  • Components 1. Identification data 2. Informants 3. Chief complaints 4. H/o Present Illness 5. Treatment history 6. Past history of illness a) Medical/surgical illness: b) Past psychiatric history : 7 Family history:
  • Components 8. Personal history a. Perinatal history b. Childhood history c. Educational history d. Play history e. Emotional problems during adolescence f. Puberty g. Obstetrical history h. Occupational history i. Sexual and marital history j. Premorbid personality
  • I. IdentIfIcatIon data
  • IdentIfIcatIon data: Name : Age : Sex : Marital status: Religion: Education: Occupation : Income Address: Date of admission: Hospital No : Psychiatric ward : ♣marital status♣
  • Informants
  • II Informants: The sources of the information: Informant’s name The reliability of the sources • Relation to Patient: • Intimacy with the patient • Interest of the patient’ • Does the Informant live with the patient? • Duration of stay with the patient • Intellectual and observational ability
  • III CHIEF COMPLAINTS ON ADMISSION Presenting complaints and/or reasons for consultation should be recorded. Both the patient’s and the informant’s version should be recorded separately it should be recorded even if the patient is unable to speak and the patient explanation regardless of how bizarre or irrelevant
  • Chief complaints on admission  Patient's problem or reason for the visit Recorded as the patient's own words  Ask leading questions such as -"What brings you here today?“ -How can I help you?”
  • • Examples: • ”am having thoughts of wanting to harm myself” • “peoples are trying to drive me insane” • “I feel am going mad” • “am angry all the time “
  • Present Illness Present Illness
  • 4. HISTORY OF PRESENT ILLNESS Provides a comprehensive and chronological picture of the events. Probably the most helpful in making an accurate diagnosis.
  • History of present illness  Duration- Weeks/months/years  Mode of onset-Abrupt/acute/subacute/Insidious  Course-( continuous / episodic/ fluctuating/ deteriorating/ improving/ unclear)  Precipitating factors (death/ separation/ loss/ frightening experience/ any other)  Aggravating and relieving factors, if any.
  • HISTORY OF PRESENT ILLNESS  When the patient was well the last time should be noted.  The time of onset  When the symptoms are first noticed by the patient or by the relatives.  The symptoms of the illness from the earliest time at which a change was noticed until the present time should be narrated chronolo-gically, in a coherent manner.
  • HISTORY OF PRESENT ILLNESS  The presenting chief complaints should be expanded.  Any disturbances in the physiological functions like sleep, appetite, and sexual functioning  Always enquire about suicidal ideation  Important negative history should be recorded(eg. no h/o head injury)  Life chrt-valuable display of course of illness
  • V. TREATMENT HISTORY • Drugs- dose/route/side effects/complains • ECT • Psychotherapy • Rehabilitation Year & Month Centre Duration Treatment
  • Current medications • What medications do you take regularly and since when? • What medications have you had in the past?
  • VI. PAST HISTORY OF ILLNESS a) Past medical/surgical illness: b)Past psychiatric history
  • Past medical/surgical illness: History of chronic medical illness and details of medication received and the duration of illness  Hospitalization  Medical/neurological/surgical illness  Head injury/ convulsion/ Unconsciousness  Accidents/surgical procedure  DM/HTN/CAD/Visceral/ HIV +ve
  • Past psychiatric history • Past psychiatric illness • H/o alcohol/substance abuse/dependence
  • Past psychiatric history –Had the patient suffered from any mental illness and undergone psychiatric treatment –Has the patient been hospitalized earlier for the treatment of mental illness –What was the nature of treatment she or he had been getting; drugs or ECT –Did the patient improve with the treatment
  • ? • Any similar or other psychiatric problems in the past? • Have you ever been admitted to a psychiatric hospital? • What treatments have you had? • Has there ever been a time that you felt completely well?
  • VII FAMILY HISTORY a. Family structure b. Family history of illness o Psychiatric illness- similar/other o Major medical illness o Alcohol/drug dependence/suicidal attempt
  • c. Current social situation o Home circumstances o Per capita income o Socioeconomic status o Head of the family-nominal & functional o Current attitude of the family members towards the patient’s illness o Communication pattern in the family o Cultural &religious values o Social support system available
  • ? • Are your parents still living? Are they well? • Do you mind me asking how they died? • What did your parents do? • Do you have any brothers or sisters? Are you close to them? • As far as you know, has anyone in your family ever had problems with their mental health?
  • IV Personal history
  • PERSONAL HISTORY a. Perinatal history Antinatal Any febrile illness Physical/Psychiatric illness Medications/drugs/alcohol use Trauma to abdomen Immunization Birth -Full term/premature/postmature Wanted/unwanted
  •  Delivery Normal/instrumental/ ceserean Birth cry Immediate/delayed Birth defects Postnatal complications Cyanosis/convulsion/jaundice Any other
  • b. Childhood history Primary care giver Whether the patient was brought up by mother/some one else Feeding Breast feed/artificial Age at weaning Developmental milestones Normal/delayed Age & ease of toilet training
  • Behavioural and emotional problems Thumb – sucking  temper tantrums  tics, head-banging  night terror  fears  bed-wetting nail-biting. Stuttering/stammering Enuresis/ encopresis Somnambulism
  • ? • Where were you born? • Where did you grow up? • As far as you know, was your mother’s pregnancy and delivery normal? • If not, were there any problems around the time of your birth? • Did you have any serious illnesses as a young child? • Were you walking and talking at the correct times?
  • c. Educational history Age at begining&finishing formal education Academic and extra curricular achievements- if any Relationship with peers &teachers School phobia Truancy, non-attendance Learning disabilities Reason for termination of studies(if occures prematurely)
  • ?• Which school/s did you go to? • Did you enjoy school? • Any lasting memories of school? • Did you have many friends at school? Still in contact? • When did you finish school ? Qualifications? • Were you ever in trouble at school? ever expelled or suspended? Bullied?
  • d. Play history  Games played At what age &with whom Relationships with playmates
  • e. Emotional problems during adolescence Running away from home delinquency smoking drug use anyother
  • f. Puberty • Age at appearance of secondary sexual characteristics • Anxiety related to puberty changes • Age at menarche • Reaction to menarche • Regularities of cycle & duration of flow • Abnormalities if any(menorragia/dysmenorrea)
  • g. Obstetrical history LMP Any abnormalities associated with pregnancy/ delivery/ puerperium Number of children Termination of pregnancy Reaction to menopause
  • h. Occupational history Age at starting work Jobs held in chronological order Reasons for change, if any Current job satisfaction (including relationship with authorities ,peers and if applicable ,subordinates). Whether job is appropriate to client’s back ground
  • i. Sexual and marital history • Type of marriage: self choice/ arranged • Duration of marriage • Interpersonal relationship with in-laws: satisfactory/ unsatisfactory • Details of spouse and children
  • J. Premorbid personality a.Interpersonal relationships  Interpersonal relationship with family members, friends, work-mates and superiors  Introverted/extraverted  ease of making and keeping social relations. a.Use of leisure time o Hobbies o Interests o Intellectual activities o energetic/sedentary.
  • a. Predominant mood o Optimistic/pessimistic o Stable/prone to anxiety o Cheerful/despondent o Reaction to stressful life events. a. Attitude to self & others o Self-confidence level o self-criticism & self-consciousness o selfish/thoughtful of others o self-appraisal of abilities, o achievements and failures. o General attitude towards others
  • a. Attitude to work and responsibilities b. Decision making c. acceptance of responsibility d. flexibility e. foresight. f. Religious beliefs and moral attitudes g. Fantasy life Day dreams –frequency and contents
  • a. Habits • Eating pattern: regular/ irregular • Elimination: regular/ irregular • Sleep: regular/ irregular • Use of drugs/alcohol/tobacco