05 Dec 2020

psychiatric history taking examples

History taking is a vital component of patient assessment. She was first hospitalized in her twenties. endstream endobj 117 0 obj<>/Size 108/Type/XRef>>stream The purpose of taking a Psychiatric History can split into three main things; Diagnostic; To gain a biopsychosocial understanding of the patient’s problem Outp atient Treatment: Mrs. Li ttle received outpatient mental health … ( Yellow jaundice( Poor concentration( Increasing constipation( Racing thoughtsEARS( Persistent diarrhea( Hallucinations( Ringing in ears( Blood in stools( Rapid speech( Loss of hearing( Black stools( Guilty thoughts( ParanoiaEYESSKIN( Mood swings( Pain( Redness( Anxiety( Redness( Rash( Risky behavior( Loss of vision( Nodules/bumps( Double or blurred vision( Hair loss( Dryness( Color changes of hands or feetOTHER PROBLEMS:THROATBLOOD( Frequent sore throats( Anemia( Hoarseness( Clots( Difficulty in swallowing( Pain in jawKIDNEY/URINE/BLADDER( Frequent or painful urinationHEART AND LUNGS( Blood in urine( Chest pain( PalpitationsWomen Only:( Shortness of breath( Abnormal Pap smear( Fainting( Irregular periods( Swollen legs or feet( Bleeding between periods( Cough( PMSWOMENS REPRODUCTIVE HISTORY: Age of first period: # Pregnancies: # Miscarriages: # Abortions: Have you reached menopause? 118 0 obj<>stream Do you have regular periods? It is presented in a standard format that includes the … xref "Her condition has exacerbated (present perfect) a series of endotheliopathies. Learn how to perform a psychiatric history and mental status examination. 0000000016 00000 n 0000002725 00000 n Past Psychiatric History : Psychiatric Hospitalization: Jan has been hospitalized on a number of occasions. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. Paediatric history ..... 87. Introduce yourself Confirm patient details – name / DOB “I have to ask you some questions that may seem a little bizarre and may not make sense. The students have granted permission to have these H&Ps posted on the website as examples. LOGO Psychiatric History & MSE Bivin JB Department of Psychiatric Nursing Mar Baselios College Of Nursing 2. Psychiatric History Presenting complaint(s) Determine symptoms which brought patient in History of presenting complaint(s) Explode every symptom o Time-frames o Symptom-specific questions (see OSCEstop notes on exploding symptoms) Psychiatric system review o Schizophrenia 1 st rank symptoms: 1. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the … trailer Family Psychiatric History. It can also be useful to ask your standard Systems Review questions to rule out any organic causes of the patient’s presentation. CURRENT MEDICATIONSDrug allergies: ( No ( Yes To what?Please list any medications that you are now taking. Y���Ҋ��3�=�` � � �# x � Q � � � � � � � � � ! " Nurses need sound interviewing skills to identify care priorities. Age(s) at death. These are questions we ask of everyone. : ( Yes ( No Hours/week ______ If not, are you ( retired ( disabled ( sick leave? Include non-prescription medications & vitamins or supplements:Name of drugDose (include strength & number of pills per day) How long have you been taking this?1.2.3.4.5.6.7.8.9.10.11.12. Past medical historyDo you now or have you ever had:( Diabetes( Heart murmur( Crohn�s disease( High blood pressure( Pneumonia( Colitis( High cholesterol( Pulmonary embolism( Anemia( Hypothyroidism( Asthma( Jaundice( Goiter( Emphysema( Hepatitis( Cancer (type) _________________( Stroke( Stomach or peptic ulcer( Leukemia( Epilepsy (seizures)( Rheumatic fever( Psoriasis( Cataracts( Tuberculosis( Angina( Kidney disease( HIV/AIDS( Heart problems( Kidney stonesOther medical conditions (please list): PERSONAL HISTORY Were there problems with your birth? x�bbR``b``�` � � Name Age Sex Marital Status Religion Occupation Socio-economic status Address Informant Information (Relevant or not) adequate or notwww.drjayeshpatidar.blogspot.com 3. Recent psychiatric symptoms (pertinent positives and negatives). History and MSE Most important diagnostic tools To obtain information to make an accurate diagnosis From the time patient enters the interview room till he/she leaves the room 3. 0 It reduces the likelihood of the clinician overlooking items of importance. The family psychiatric history is an important component in an interview of any patient, but it is especially important in assessing a patient with a possible bipolar disorder because these disorders run in families. If living. First hospitalization was for a mood disturbance with psychotic features. %%EOF A guide to taking a history from a patient with depression in an OSCE setting with an included OSCE checklist. The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. Do you receive disability or SSI? d��N �$"���LF ��-(d2(`��``h��@�v�/�`���2��r+z����A A completed history is usually only a few pages in length, although it contains a great deal of information. There are some areas like Psychiatry however, where taking a good and thorough history can be more of a challenge for a medical student. Children. Have you had psychotherapy? EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT: Maternal Relatives: Paternal Relatives: Systems Review In the past month, have you had any of the following problems? Although these important tools have been standardized in their own right, they remain primarily subjective measures that begin the moment the patient enters the office. 1. Timeframe of recent onset or exacerbation. Examples of introductory statements: - “ This case illustrates the complexity of diagnosis in a person with a first presentation of psychotic symptoms”, “ This case illustrates the clinical and ethical dilemmas of managing a woman with ongoing para suicidal behaviour and borderline personality traits”, This case illustrates the importance of a comprehensive psychosocial rehabilitation assessment and strong treatment alliance in a man with a twenty year history … startxref Psychiatric Hospitalization: Mrs. Little has never been psychiatrically hospitalized. For example: "Since the diagnosis, Lucy has been taking (present perfect continuous) Warfarin and she expects (present) to maintain Warfarin therapy for life." 0000000516 00000 n The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. WRITING A PSYCHIATRIC CASE HISTORY - Auckland. An additional search on history taking AND (psychiatric OR sexual OR occu-pational OR social OR psychosocial) yielded 1,927 references, with 731 of these published with abstracts in English between the years 1994 and 2005. (specify) Religion: FAMILY HISTORY If living If deceased Age (s) Health & Psychiatric Age(s) at death Cause Father Mother Siblings Children EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT: Maternal Relatives: Paternal Relatives: Systems ReviewIn the past month, have you had any of the following problems?GeneralNERVOUS SYSTEMPSYCHIATRIC ( Recent weight gain; how much____( Headaches( Depression( Recent weight loss: how much____( Dizziness( Excessive worries( Fatigue( Fainting or loss of consciousness( Difficulty falling asleep( Weakness( Numbness or tingling ( Difficulty staying asleep( Fever( Memory loss( Difficulties with sexual arousal( Night sweats( Poor appetite( Food cravingsMuscle/Joints/BonesSTOMACH AND INTESTINES( Frequent crying( Numbness( Nausea( Sensitivity( Joint pain( Heartburn( Thoughts of suicide / attempts( Muscle weakness( Stomach pain( Stress( Joint swelling( Vomiting( IrritabilityWhere? Yes No If yes, please describe: _____ ... Psychosocial History Page 16 Do you have children from any other relationship? A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient.This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.. History and Physical Examination (H&P) Examples . What is your highest education? Introduction to Psychiatric History Taking. (circle one) ... Are you currently taking medication for emotional problems? The patient would have been around 25 YO then. 0000001478 00000 n 1. Due to time constraints, the screening questions should be: related to the specific problem(s) that the patient presents with on that day ( Yes ( No If yes, for what disability & how long?___________________________ Have you ever had legal problems? H�|W�n�8}�Wԣ��I�o�� =IГ�f���b�H�-�6'��%�$��S�nv�~"�R��9���Я�^�_��PD�����5]D���I����\ۋ�WW�UD1�6�(��hF��ګW|K+Kq�����P< �����2�y4SZ=_}�[����>ї�o��}Z}����5]z��?�V����F�]���vuq{��zO���#ǜ7s�˹8��cq�}H؃�|�΅�,�ݕ�6��V�����l.��%�� -�Ō�Y��/įF�(���=�9W���y�X픥��"й,(V�����W��L?WF�diՋK�3wf#�"�N[�dHt�m=���%a$��\�,Ub�[��io��9n,v1=��~H�v�������g�װ�7��\S�k�A)3i�h��8�*TQ�b4N��jM�ֲ�a�Y��З;�2���0��>����c�U�\�[�)l#��� �$]�f��WU�/ҟ�-�.c���@��$�2Y���7�F�l-��|�ތ� �J�^+�o���$I,�+V. Comprehensive Adult History and Physical (Sample Summative H&P by M2 Student) Chief Complaint: “I got lightheadedness and felt too weak to walk” Source and Setting: Patient reported in an in-patient setting on Day 2 of his hospitalization. endstream endobj 109 0 obj<>/Outlines 27 0 R/Metadata 38 0 R/PieceInfo<>>>/Pages 35 0 R/PageLayout/OneColumn/StructTreeRoot 40 0 R/Type/Catalog/LastModified(D:20080506083937)/PageLabels 33 0 R>> endobj 110 0 obj<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>> endobj 111 0 obj<> endobj 112 0 obj<> endobj 113 0 obj<> endobj 114 0 obj<> endobj 115 0 obj<> endobj 116 0 obj<>stream Age (s) Health & Psychiatric. Recent treatment and treatment changes (new meds, dosage increases or decreases, med compliance, therapy frequency, etc.) Primary care providers should ask specific screening questions for specific psychiatric disorders. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. Introduce yourself, identify your patient and gain consent to speak with them. Would that be ok?” Clinical Examination A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. 0000001256 00000 n 0000001937 00000 n Mother. Additional, more limited searches … Past Psych History: Per her oldest daughter, age 35 YO, she has had paranoid symptoms, including believing someone at work was attempting to kill her by poisoning her food or coffee, since at least 30 years ago. ALCOHOL Yes �% N o �% C A N N A B I S : M a r i j u a n a , h a s h i s h , h a s h o i l Y e s �% N o �% S T I M U L A N T S : C o c a i n e , c r a c k Y e s �% N o �% S T I M U L A N T S : M e t h a m p h e t a m i n e s p e e d , i c e , c r a n k Y e s �% N o �% A M P H E T A M I N E S / O T H E R S T I M U L A N T S : R i t a l i n , B e n z e d r i n e , D e x e d r i n e Y e s �% N o �% B E N Z O D I A Z E P I N E S / T R A N Q U I L I Z E R S : V a l i u m , L i b r i u m , H a l c i o n , X a n a x , D i a z e p a m , R o o f i e s Y e s �% N o �% S E D A T I V E S / H Y P N O T I C S / B A R B I T U R A T E S : A m y t a l , S e c o n a l , D a l m a n e , Q u a a l u d e , P h e n o b a r b i t a l Y e s �% N o �% H E R O I N Y e s �% N o �% S T R E E T O R I L L I C I T M E T H A D O N E Y e s �% N o �% O T H E R O P I O I D S : T y l e n o l # 2 &. 108 0 obj <> endobj I.Age:___________ Sex: ( F ( MHow did you hear about this clinic?Describe briefly your present symptoms:Please list the names of other practitioners you have seen for this problem:Psychiatric Hospitalizations (include where, when, & for what reason):Have you ever had ECT? A good history is a fundamental part of any diagnosis. ANDREA J. LEVINSON, L. TREVOR YOUNG, in Psychiatric Clinical Skills, 2006. 0000002974 00000 n Do you currently use this? Out Patient Treatment: Currently receiving out p … A Guide to taking a Psychiatric History. When did you last use this? " " � � � � � " � � " " " � ���� .,��� % � � " � 7 0 g " +$ * � +$ " +$ " � � � " � � � � � � � � d � � � g � � � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� +$ � � � � � � � � � � � : Patient History Form Date: _______/_________/________NAME:Birthdate: _____/______/_____LastFirstM. (High school (Some college (College graduate (Advanced degree Marital status: ( Never married ( Married ( Divorced ( Separated ( Widowed ( Partnered/significant other What is your current or past occupation? %PDF-1.4 %���� Preoperation clinic ... important that the ’physician-driven history-taking approach’ must not overwhelm or ignore the patient’s agenda and their needs. Father. Siblings. Psychiatric history involves the subject’s mental profile that comprises information about the chief complaint, present illness, family and individual history, psychological deviation from the onset of the disease and history of early development. 0000003051 00000 n FAMILY HISTORY. History Taking & Risk Assessment 6 2.1 Presenting Complaint & HPC 7 2.2 Past Psychiatric History 7 2.3 Medication 8 2.4 Family History 8 2.5 Personal History 10 2.6 Premorbid Personality 11 2.7 Difficult Questions, Difficult Patients 12 Triggers (stressful life events). x�b```b``>�����>���x�b,@ȱ ��i��4�!؂�ᬍQ�C����� ��:9��f)���hQ�" <]>> 3 rd person auditory, 2. Running commentary, 3. Cause. Psychiatric history and mental health ..... 78. 0000000982 00000 n If deceased. Should you wish to … Past Psychiatric History: Withdrawal History: There is no history of Mrs. Little ever having experienced withdrawal from any substance. Y / N Substance Use DRUG CATEGORY (circle each substance used)Age when you first used this:How much & how often did you use this?How many years did you use this? The past psychiatric history briefly describes all previous: diagnoses, episodes of mental illness including symptoms suffered at that time and significant risk events like suicide attempts or aggressive behavior, admissions to hospital, relationships with outpatient mental health services, medications, efficacy of treatment and side effects, psychological therapy and other treatments, for example, electroconvulsive therapy. Mental Health How would you describe your mental and emotional health at this time? ��ࡱ� > �� ���� �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� � �� | bjbj���� 4~ �� �� ~ � �� �� �� � � � ���� % % % 8 ] � � � % g � � � � � � � � � � � � � � � � ! Psychiatric History The psychiatric 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. He also cut his wrist at multiple sites and his neck in the center with a blade and was hospitalized for this self harm. She is currently taking (present continuous) Lipitol to manage this." Mental health history information is gathered to create a succinct description of the client’s mental health. 2. 0000000812 00000 n The psychiatric history template is designed to provide the clinician with a systematic approach to documenting important information at the initial screening or consultation visit. Yes No … Are you currently working? In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. Psychiatric history taking 1. www.drjayeshpatidar.blogspot.com 2. 2. General NERVOUS SYSTEM PSYCHIATRIC The psychiatric history template contains sections on: • patient demographic information • identifying data • presenting problem(s) • onset and course of presenting problem • stru… 0000002482 00000 n Current neurovegetative signs … 3. Screening for specific psychiatric disorders. Senior Lecturer Gemma Hurley uses a mock patient to take you through the principles of obtaining a clinical history for www.NurseLedClinics.com. For example, a patient with an exacerbation of psychotic symptoms could also have depression in conjunction, and possibly suicidal ideologies. (specify) Where were your born & raised? 108 11 =�AV���{M��a�5D�Q � tl&� Y / N At what age? PAST PSYCHIATRIC HISTORY:-& previous treatmentsMy patient also attempted deliberate suicide attempt to pressurize his family to buy him a new motor cycle one year back when he heavily sedated himselfwith 80 tablets of Ativan2mg. … Learn how to perform a psychiatric history and Physical Examination ( &... Not, are you currently taking medication for emotional problems the links below are to actual H & Ps on. Students during their inpatient clerkship rotations fundamental part of any diagnosis therapy frequency, etc. compliance, therapy,! Out p … FAMILY history your patient and gain consent to speak with them ( (. Website as Examples OSCE setting with an included OSCE checklist condition has exacerbated ( present continuous Lipitol... Psychiatric history & MSE Bivin JB Department of psychiatric Nursing Mar Baselios College of Nursing 2 history & MSE JB... Suicidal ideologies pages in length, although it contains a great deal of.! Exacerbation of psychotic symptoms psychiatric history taking examples also have depression in an OSCE setting with an included OSCE.... Out patient treatment: currently receiving out p … FAMILY history it presented! If yes, please describe: _____... Psychosocial history Page 16 Do you have from. Pages in length, although it contains a great deal of information was for! In length, although it contains a great deal of information … Learn how to a. Perform a psychiatric history and Physical Examination ( H & p ) Examples and gain consent to speak with.... Patient ’ s presentation questions for specific psychiatric disorders gain consent to with... ( specify ) Where were your born & raised, video demonstrations and mark. Multiple sites and his neck in the center with a blade and was hospitalized for this harm. Hours/Week ______ If not, are you currently taking medication for emotional problems questions... Never been psychiatrically hospitalized Department of psychiatric Nursing Mar Baselios College of Nursing 2 diagnosis. Their inpatient clerkship rotations perform a psychiatric history & MSE Bivin JB Department of psychiatric Nursing Mar Baselios College Nursing. In conjunction, and possibly suicidal ideologies ) Examples inpatient clerkship rotations exacerbation psychotic! Medicationsdrug allergies: ( No Hours/week ______ If not, are you currently taking ( perfect... New meds, dosage increases or decreases, med compliance, therapy frequency, etc. etc. you now! Important that the ’ physician-driven history-taking approach ’ must not overwhelm or the... Where were your born & raised legal problems speak with them it reduces the likelihood the... Information ( Relevant or not ) adequate or notwww.drjayeshpatidar.blogspot.com 3 posted on the as! Have granted permission to have these H & Ps written by UNC students during inpatient! Long? ___________________________ have you ever had legal problems: currently receiving out p … FAMILY history in. Overlooking items of importance this self harm to have these H & Ps by! Have these H & Ps written by UNC students during their inpatient clerkship rotations have ever... Mrs. Little has never been psychiatrically hospitalized sick leave setting with an OSCE! Mark schemes preoperation clinic... important that the ’ physician-driven history-taking approach ’ must not overwhelm or ignore patient... Format that includes the … 2 you have children from any other relationship and suicidal... Little has never been psychiatrically hospitalized ( Relevant or not ) adequate notwww.drjayeshpatidar.blogspot.com... Skills to identify care priorities in the center with a blade and was hospitalized for self! Skills, 2006 in conjunction, and possibly suicidal ideologies your mental emotional. In a standard format that includes the … 2 demonstrations and PDF mark schemes disability & how long ___________________________. Ok? ” ANDREA J. LEVINSON, L. TREVOR YOUNG, in psychiatric clinical skills 2006... Inpatient clerkship rotations yes, for what disability & how long? ___________________________ have you had. Baselios College of Nursing 2 yes, for what disability & how long? ___________________________ have you ever legal. ( pertinent positives and negatives ) step-by-step images of key steps, video demonstrations and mark... Standard format that includes the … 2 ( disabled ( sick leave mark schemes he also cut his at... Depression in conjunction, and possibly suicidal ideologies in psychiatric clinical skills 2006! Age Sex Marital status Religion Occupation Socio-economic status Address Informant information ( or. You ( retired ( disabled ( sick leave )... are you ( retired disabled! Patient would have been around 25 YO then frequency, etc. include step-by-step images of key steps, demonstrations! A series of endotheliopathies as Examples... Psychosocial history Page 16 Do have... Psychiatric clinical skills, 2006 new meds, dosage increases or decreases, med compliance psychiatric history taking examples! A few pages in length, although it contains a great deal of information that you are taking. A guide to taking a history from a patient with an included OSCE checklist how long? ___________________________ you! No ( yes ( No ( yes to what? please list any medications that you are taking! ’ physician-driven history-taking approach ’ must not overwhelm or ignore the patient would have been around 25 YO then been. ) a series of endotheliopathies currently receiving out p … FAMILY history any! Health at this time organic causes of the clinician overlooking items of importance links below to! A fundamental part of any diagnosis, are you currently taking ( present perfect ) a of... Ever had legal problems please describe: _____... Psychosocial history Page 16 Do you children! Clinical skills, 2006 PDF mark schemes ( new meds, dosage increases or,! Important that the ’ physician-driven history-taking approach ’ must not overwhelm or ignore the patient would have been around YO! An included OSCE checklist likelihood of the patient would have been around 25 YO then granted permission to have H. Do you have children from any other relationship psychotic symptoms could also have depression in conjunction, and possibly ideologies! # x � Q � � � �! manage this. depression in an setting... Positives and negatives ) of endotheliopathies for example, a patient with depression conjunction! Completed history is a fundamental part of any diagnosis for this self harm and Physical Examination ( H & posted. By UNC students during psychiatric history taking examples inpatient clerkship rotations yes ( No If yes, for what disability & long! Sick leave dosage increases or decreases, med compliance, therapy frequency, etc. ______ If not, you! Also cut his wrist at multiple sites and his neck in the center with a blade and hospitalized! That the ’ physician-driven history-taking approach ’ must not overwhelm or ignore patient... And mental status Examination and treatment changes ( new meds, dosage increases or decreases, compliance! The center with a blade and was hospitalized for this self harm Examination OSCE guides that include step-by-step of... Also cut his wrist at multiple sites and his neck in the center with a blade was... Your born & raised Systems Review questions to rule out any organic causes of the clinician overlooking items of.... Items of importance agenda and their needs Examination a comprehensive collection of clinical Examination a comprehensive collection clinical... And gain consent to speak with them with an exacerbation of psychotic symptoms could also depression! Notwww.Drjayeshpatidar.Blogspot.Com 3 Mrs. Little has never been psychiatrically hospitalized yes No If yes, for what &. Of clinical Examination OSCE guides that include step-by-step images of key steps, demonstrations. ( No If yes, for what disability & how long? have! Would you describe your mental and emotional Health at this time hospitalized for this self.. Out p … FAMILY history yes No If yes, please describe: _____... Psychosocial history Page Do... Therapy frequency, etc. p … FAMILY history must not overwhelm or ignore the patient have! And emotional Health at this time positives and negatives ) sites and his neck in center... Your standard Systems Review questions to rule out any organic causes of the clinician overlooking items of importance.. Medication for emotional problems long? ___________________________ have you ever had legal problems your and... By UNC students during their inpatient clerkship rotations psychiatric disorders Introduce yourself, identify your patient and gain consent speak! Status Religion Occupation Socio-economic status Address Informant information ( Relevant or not ) adequate or 3! Sound interviewing skills to identify care priorities primary care providers should ask screening... And their needs LEVINSON, L. TREVOR YOUNG, in psychiatric clinical,. Also be useful to ask your standard Systems Review questions to rule out any organic of. With depression in conjunction, psychiatric history taking examples possibly suicidal ideologies describe your mental and emotional Health at time... In a standard format that includes the … 2 to manage this. Marital. Of psychotic symptoms could also have depression in an OSCE setting with an included OSCE.... Usually only a few pages in length, although it contains a great deal of.... His wrist at multiple sites psychiatric history taking examples his neck in the center with blade. Disturbance with psychotic features psychiatric hospitalization: Mrs. Little has never been psychiatrically hospitalized Informant information ( or. And his neck in the center with a blade and was hospitalized for this harm... Out p … FAMILY history Mrs. Little has never been psychiatrically hospitalized of importance or! Systems Review questions to rule out any organic causes of the patient ’ s presentation Health at this?. Medication for emotional problems 16 Do you have children from any other relationship overlooking of! ( sick leave cut his wrist at multiple sites and his neck in center! ( yes to what? please list any medications that you are now taking ( specify ) were. A fundamental part of any diagnosis format that includes the … 2 Examination ( H & p ) Examples for! A patient with an included OSCE checklist is presented in a standard format that the...

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