Importance of Case History Taking and Mental Status Examination Case history is the record of patient’s life. The history is a patient’s life story told to the psychiatrist in the patient’s own words from his or her own point o view. It allows the psychiatrist to understand the patient and also helps in prognosis of the case. The history also includes information about the patient obtain from other sources such as parents or spouse. Getting the comprehensive history from a patient or from other sources is essential. Making a correct diagnosis and formulating a specific and effective treatment plan. The assessment of a patient who may have a psychiatric disorder has several stages. It is needed to decide whether there is a disorder and if so of what kind, whether the patient is disabled and if so in what way, whether there is danger to the patient or to others, and what sort of person has become ill and what are his social circumstances. To make their decisions, a detailed history taking, mental status examination and physical examination are needed. A scheme for history taking;
* Name, Age & Address of the Patient
* Name of the Informant and their relationship to the Patient * History of Present Condition
* Family History
* Personal History
* Past Illness
* Use of Drugs, Alcohol, Tobacco etc.
Present Condition: - Symptoms with duration and mode of onset of each, the tie relations between symptoms and any physical disorder, or psychological or social problems, the nature and duration of any impairment, disability and handicap, any treatment received. Family History: - Parents’ age now or at death, if dead, cause of death, health, occupation, personality, quality of relationship with patient. Siblings names, ages, marital status, occupation, personality, psychiatric illness and quality of relationship with patient Social position of family
Atmosphere in the home
Any disorders in the family including psychiatric disorders, personality disorders or alcoholism, epilepsy When the family history is complex and relevant, it can be summarized diagrammatically as family tree. The following symbols are in general use; Squares for males, circles for females, crossed through if the person is deceased. Marriages or liaisons leading to the birth of a child indicated by a line joining the partners, crossed through with two oblique lines of the divorce or other permanent separation. Personal History: - Pregnancy and birth abnormalities
Early development, delay in talking, walking etc.
Childhood- Prolonged separation from parents relations to it Any emotional problems- Age of onset, course and treatment
Excessive fears, tantrums, shyness, stammering, blushing, sleep-walking, prolonged bed wetting, frequent nightmares Any serious illness in childhood
Schooling and higher education- Age of starting and finishing each stage, academic record, achievements, relations etc. Occupation- Chronological list of jobs with reasons for changes, present financial circumstances Menstrual History- Age of menarche attitude to periods, premenstrual tension, age of menopause Marriage and Cohabitation- Age at marriage, how long partner known, quality of present and previous relationships Sexual History- Attitude to sex, heterosexual and homosexual experiences, sexual abuse Children- Names, sex, age of children, abortions, temperament, physical, mental & emotional development of children Social Circumstances- Accommodation, household composition, financial problems Past Medical History- Illnesses, operations and accidents
Past Psychiatric Illness- Nature and duration of each illness, date, nature of treatment, current medication for physical as well as psychiatric illness. Substance Use- Alcohol, drugs, tobacco
Forensic History- Arrest, convictions, imprisonment, nature of offenses Personality
Relationships- Few or many, superficial or close, with own or opposite sex, relations with workmates...
Please join StudyMode to read the full document