historytakingandmentalstateexamination2 (1).ppt

8/14/2019 HistoryTakingAndMentalStateExamination2 (1).ppt

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History Taking And Mental

State Examination

Dr Sharmi Bhattacharyya


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Introduce yourselfExplain the purpose and approx how longit will takeStart with open questionsNever hurry a patient try to be empathic

and listen You might need an informant ( askpatients permission )


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SOCIO DEMOGRAPHIC DETAIL

Name Age

DOB AddressOccupation

Marital status


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H/O PRESENTING C/O

Reason for referral: Referred by..

What are the main problems?Which of these are the worst?How has that affected you?

Any precipitating factorsWhen did you last feel well?


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Obtain a clear chronological account ofsymptoms ( e.g. depression, psychosis)and the effects of these symptoms onbehaviour


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PAST PSYCHIATRIC HISTORY 1

In the past have you ever had problemswith your mental health / nerves/depression.Have you ever seen a psychiatrist before?


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PAST PSYCHIATRIC HISTORY 2

Have you ever been admitted to apsychiatric hospital?What treatments have you had?Has there ever been a time that you felt

completely well?


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PAST MEDICAL HISTORY

Do you have or had any problems withyour physical health?Have you ever had any operations or beenin hospital?


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CURRENT MEDICATIONS

What medications do you take regularlyand since when?What medications have you had in thepast?


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FAMILY HISTORY

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? Areyou close to them?

As far as you know, has anyone in yourfamily ever had problems with theirmental health?


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PERSONAL HISTORY 1

Infancy and early childhood

Where were you born?Where did you grow up?

As far as you know, was your motherspregnancy and delivery normal?


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PERSONAL HISTORY 2

If not, were there any problems aroundthe time of your birth?Did you have any serious illnesses as ayoung child?Were you walking and talking at thecorrect times?


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PERSONAL HISTORY 3

Adolescence and education

Which school/s did you go to?Did you enjoy school? Any lasting memories of school?


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PERSONAL HISTORY 3

Did you have many friends at school? Stillin contact?When did you finish school ?

Qualifications?Were you ever in trouble at school? everexpelled or suspended? Bullied?


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PERSONAL HISTORY 4

What did you do after finishing school?Occupational record

Sexual development,Relationships and marriageDo you have any children? How old are

they?


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PERSONAL HISTORY 5

Present social circumstancesWho lives at home with you now?

Do you have any worries about debt ormoney in general?Do you have friends or family who live

nearby?


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PREMORBID PERSONALITY 1Before all this happened, how would youdescribe yourself?How would other people describe you?

When you find yourself in difficult situations,how do you cope?What sort of things do you like to do torelax?


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PREMORBID PERSONALITY 2

Do you have any hobbies?Do you like to be around other people or doyou prefer your own company?

Are you religious?Do you have any ambitions or plans?


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ALCOHOL AND DRUG HISTORY

Do you smoke? How many? Since when?Do you take a drink?

How much do you drink?Have you been drinking any more or lessthan normal recently?

Have you ever taken drugs? Tell me moreabout that.


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FORENSIC HISTORY

Have you ever been in trouble with thepolice, or been convicted of anything?

***


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MENTAL STATEEXAMINATION


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APPEARANCE, ATTITUDE AND BEHAVIOUR 1

Describe appearance: Body habitus; prominent physicalcharacteristics: tattoos, scars, needlesites; grooming and attireLevel of consciousness, apparent age,position and posture, eye contact, facialexpressions,rapport


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APPEARANCE, ATTITUDE AND BEHAVIOUR 2

Describe attitude: Degree and type of co-cooperativeness,resistance Describe activity:

Voluntary movements and their intensity,

involuntary movements Automatic movements, Tics, mannerisms,compulsions


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SPEECH AND LANGUAGE

Assess for:Fluency of speech (rate and volume)

RepetitionContent of speech


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MOOD AND AFFECT

Describe predominant mood in patientsown words

Associated biological symptoms andsuicidality or homicidalityDescribe affect and reactivity


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THOUGHT

DESCRIBE FORM OF THOUGHT:

Degree of connectedness (looseassociations, tangentiality, etc.)Presence of peculiarities (clangassociations, blocking, neologisms, etc.)


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THOUGHT CONTENT 1

Describe thought content: Predominanttopic or issues; Preoccupations,ruminations, obsessions; Suicidal orhomicidal ideation; Phobias.


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THOUGHT CONTENT 2

ABNORMAL BELIEFS: Describe any delusions, thoughtinterference, reference or persecution,control or passivity phenomenon, nihilisticor grandiose ideas/ delusions


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PERCEPTUAL ABNORMALITIES

Illusions

Hallucinations- sensory experience in theabsence of a stimulus-various types (auditory, visual, gustatory, tactile).


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COGNITION USUALLY MMSE WOULD DO

General: Alertness and Co-operation[STM: Name, Address, Flower toremember] Orientation: Time and Place

A ttention: WORLD backwards and SerialSevens Language: Naming and Repetition


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COGNITION USUALLY MMSE WOULD DO

Calculation: Division and Subtraction R ight Hemisphere Function: Intersectingpentagons and Clock-face

Abstraction: Proverbs and Similarities Memory: STM and Long-term memory

P raxis: Wave good-bye and Comb hair


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INSIGHT AND JUDGEMENT

Awareness of disease: Do you consider that you are ill in any way? Whyhave you come into hospital? Do you have a

physical or a mental illness? If you have amental illness, what is it? Correct labelling of abnormality:

You described several symptoms..namely. What is your explanation of these experiences?


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Willingness to take treatment :

How do you feel about being inhospital..? Coming to the clinic.? How

do you feel about taking medication? Hasthe medication been helpful? Have anyother treatments been helpful? Do youthink that medication helps you to remainwell?


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Remember to always do aPHYSICAL EXAMINATION

!!!!

General observations: Vital signs: HR, BP,RR, Temp: Autonomic arousal, tremor,sweating etc.Important features: scars, tattoos, signs ofliver disease, signs of thyroid or Cushingsdisease, etc., Specific CVS, RS, GI, andCNS examination findings and importantnegative findings

historytakingandmentalstateexamination2 (1).ppt

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