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    History Taking in Psychiatry & Mental State Examination PDF

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    Mersing Haken
    This document provides an overview of history taking and mental state examination in psychiatry. It discusses the importance of history taking, as most diagnostic information comes from the patient's history and observed appearance and behavior. It then lists 13 areas of inquiry for a psychiatric history: 1) personal data, 2) informant, 3) reason for referral, 4) presenting complaints, 5) history of presenting complaints, 6) stressors, 7) family history, 8) personal history, 9) substance use, 10) past medical history, 11) past psychiatric history, 12) forensic history, and 13) premorbid personality. It also outlines 7 areas to examine for a mental state examination.

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    History Taking in Psychiatry & Mental State Examination PDF

    Uploaded by

    Mersing Haken
    227 views30 pages
    This document provides an overview of history taking and mental state examination in psychiatry. It discusses the importance of history taking, as most diagnostic information comes from the patient's history and observed appearance and behavior. It then lists 13 areas of inquiry for a psychiatric history: 1) personal data, 2) informant, 3) reason for referral, 4) presenting complaints, 5) history of presenting complaints, 6) stressors, 7) family history, 8) personal history, 9) substance use, 10) past medical history, 11) past psychiatric history, 12) forensic history, and 13) premorbid personality. It also outlines 7 areas to examine for a mental state examination.

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    History_taking_in_Psychiatry_&_Mental_State_Examination.pdf

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    This document provides an overview of history taking and mental state examination in psychiatry. It discusses the importance of history taking, as most diagnostic information comes from the patient's history and observed appearance and behavior. It then lists 13 areas of inquiry for a psychiatric history: 1) personal data, 2) informant, 3) reason for referral, 4) presenting complaints, 5) history of presenting complaints, 6) stressors, 7) family history, 8) personal history, 9) substance use, 10) past medical history, 11) past psychiatric history, 12) forensic history, and 13) premorbid personality. It also outlines 7 areas to examine for a mental state examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    227 views30 pages

    History Taking in Psychiatry & Mental State Examination PDF

    Uploaded by

    Mersing Haken
    This document provides an overview of history taking and mental state examination in psychiatry. It discusses the importance of history taking, as most diagnostic information comes from the patient's history and observed appearance and behavior. It then lists 13 areas of inquiry for a psychiatric history: 1) personal data, 2) informant, 3) reason for referral, 4) presenting complaints, 5) history of presenting complaints, 6) stressors, 7) family history, 8) personal history, 9) substance use, 10) past medical history, 11) past psychiatric history, 12) forensic history, and 13) premorbid personality. It also outlines 7 areas to examine for a mental state examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 30
    At a glance
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    The document outlines the process and important aspects of taking a psychiatric history and conducting a mental state examination on a patient.

    A psychiatric history aims to gather information on the patient's personal details, presenting complaints, stressors, family history, personal history, substance use, past medical/psychiatric history and more.

    During a mental state examination, a psychiatrist assesses the patient's appearance, speech, mood, thought content, perception, cognitive functions and insight into their condition.

    History taking in

    Psychiatry & Mental


    State Examination
    Dr. Janaka Pushpakumara
    Department of Psychiatry
    FMAS/RUSL
    History taking in Psychiatry
    Illness
    Healthy person Patient

    Home Hospital
    Heath Care System
    Healthy person Patient

    Home
    Rx Hospital
    Rx
    Process of
    Management

    Ex

    ?
    In Psychiatry

    Most of the diagnostic information

    coming from the History and

    Observation of patients’ appearance

    and behaviour.

    Very Important
    History taking in Psychiatry

    1. Personal Data:
    Name, age, marital status,
    occupation, address.
    2. Informant:
    Name, relationship to patient and
    your impression of the informant’s
    reliability
    History taking in Psychiatry Cont.

    3. Reason for referral :


    the immediate reason which
    caused the patient to seek
    treatment /be brought to hospital
    History taking in Psychiatry Cont.

    4. Presenting complaints and duration:


    The Symptoms (in brief) and
    their duration
    History taking in Psychiatry Cont.

    5. History of presenting complaints:

    • A description of the symptoms and their


    duration, including:
    • how the symptoms began, and how the
    symptoms changed with time (e.g.
    Increasing gradually or stepwise
    /remained the same/episodic in nature)
    History taking in Psychiatry Cont.

    5. History of presenting comp.

    • Changes in biological functions (e.g.


    Sleep, appetite, weight)
    • affect of symptoms on patient’s
    relationships, day to day activity and
    work
    • association between symptoms and any
    stressors or life events
    • Any other relevant information
    History taking in Psychiatry Cont.

    6. Stressors :
    Psychological or Physical
    History taking in Psychiatry Cont.

    7. Family history:
    • age and occupations of parents and the
    parent’s relationship with one another
    • general information about siblings
    • the patient’s relationship with his
    parents and siblings
    • social standing of the family
    • history of psychiatric illness, suicide or
    substance misuse in the family
    • Any other relevant information
    History taking in Psychiatry Cont.

    8. Personal history:

    • Antenatal and birth history


    • Early developmental history
    • Health in childhood
    • Occupational history
    • Marital history
    • Sexual history
    History taking in Psychiatry Cont.

    9. Substance use:

    • History of substance use : alcohol,


    nicotine, cannabis, other drugs of use
    • Duration of use : amount used at present
    and frequency of use
    • Associated problems (e.g.
    legal/financial/social problems
    secondary to substance misuse)
    History taking in Psychiatry Cont.

    10. Past medical/surgical history:


    History taking in Psychiatry Cont.

    11. Past psychiatric history:

    • Does the patient have a past history of


    psychiatric illness? When?
    • Was the illness episodic? Or was the
    patient continuously unwell?
    • Nature of treatment received, and
    response to treatment? why ?
    • Drug adherence?
    History taking in Psychiatry Cont.

    12. Forensic history:


    History taking in Psychiatry Cont.

    13. Premorbid personality:

    • This is an attempt to get an idea about


    what sort of a person the patient was
    before he fell ill.
    History taking in Psychiatry Cont.

    13. Premorbid personality: Cont.

    Inquiry about the following features

    • Relationships:
    • Leisure activities:
    • Character:
    • Attitudes and standards:
    • Prevailing mood:
    Mental State Examination
    History taking in Psychiatry Cont.

    1. Appearance and behavior:

    • General appearance

    • Posture and movement

    • Attitude towards examiner


    History taking in Psychiatry Cont.

    2. Speech:

    • Rate of speech
    • Flow of speech
    • Content of Speech
    • Volume
    History taking in Psychiatry Cont.

    3. Mood:

    • Anxious
    • Depressed
    • Elated
    • Irritable
    • Angry
    History taking in Psychiatry Cont.

    4. Content of Thought:

    • Pre occupations and/or worries?


    • Ideas and plans of suicide?
    • Ideas and plans of suicide?
    • Obsessional ideas/impulses/images
    and compulsive rituals?
    • Delusions/overvalued ideas?
    History taking in Psychiatry Cont.

    5. Disorders of Perception:

    • Hallucinations – auditory, visual,


    olfactory, gustatory, tactile
    • Illusions
    History taking in Psychiatry Cont.

    6. Cognitive Functions:

    • Level of Consciousness
    • Orientation in time, place and person
    • Attention and concentration
    • Memory – short term and long term
    • Intelligence
    History taking in Psychiatry Cont.

    7. Patient understands of illness/Insight:


    Thank You..!

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