HISTORY TAKING & M.S.E

HISTORY TAKING

1. Identification and Demo-graphical Details

Name, Age, Sex, Address, Marital status, Socio-economic status, Education, Occupation, Reference and Treating Psychiatrist, Diagnosis,  Informant – relation and address

2. Present Complaints

Symptoms – Chronological order with duration and mode of onset (acute, gradual, insidious) of each. Point out the recent complaints which lead to admission.

3. History of Presenting Complaints

Narration of presenting complaints (each symptom individually – its severity, duration, progression and also the temporal association with other symptoms)

4. History of Psychiatric Illness

Detailed account (chronological order) of the illness: – from the earliest time at which a change was noticed until admission to hospital. It includes the changes in Sleep, Appetite, Bowel habits, Interest in sex and sexual functioning, Illness impact on patient’s family, Work and social relationship, Significant life events like Death, Financial setbacks or residence, Change of jobs, Concurrent illness. It also includes any treatment taken and its effect on the symptoms.

5. Family History

Family Tree:

Parent: Age/age at the time of death with cause of death, Health, Occupation, Personality, Separations/divorce/remarriage, Patient’s relationship with one another.

Siblings: In chronological order with Names, Age, Marital status, Occupation, Personality, Health and Patient’s relationship with siblings.

Home Atmosphere: Family beliefs, Eccentricities, Race and religion and Social position.

Family History of Illness: Psychiatric disorder, Personality disorder, Epilepsy, Alcoholism drug dependence, Suicide, Mental retardation and other Neurological or Medical disorders, Marital history.

Family Dynamics

Leadership: Communication: Role functioning: Cohesion and concern: Reinforcements: Stress managing patterns: Social support: Social status of the family:

6. Personal History 

Early Development: Details of pregnancy (planned or not) and birth, Mother’s health during pregnancy, Nature of delivery, Habit training difficulties, Milestones etc. 

Health during Childhood: Infections, Movement disorders, Seizures, Hospitalization, Effect of illness on development.

Childhood Neurotic Symptoms: Nocturnal enuresis, Nightmares, Thumb sucking, Nail biting, Sleep walking, Stammering, Food fads, Mannerisms and Tantrums.

Sexual History: Menstrual history and Sexual practices.

Education: Age of starting and finishing, Type of school, Academic record, Involvement in games and sports, Relationships with teachers and other children, Hobbies and interests, Nick names, Special abilities and disabilities, Failures, etc.

Occupation: Chronological list of jobs held with reasons for change, Present financial circumstances, Satisfaction in job, Reasons for dissatisfaction, Ambitions, etc.

Marital History: Age at marriage, Arranged/love marriage, Present age – occupation – health personality of spouse, Children – age – names – personality – health, Patient’s attitude to children, Sexual satisfaction.

Treatment/Medical History: Illness, Operation, Accidents – dates, duration and hospitalization.

7. Pre-morbid Personality 

Social: Friends, Workmates, Clubs, Societies.

Use of Leisure: Hobbies or Interests.

Mood: Cheerful, Despondent, Anxious, Worrying, Irritable, Optimistic, Pessimistic, Self-depreciative, Satisfied, Overconfident, Stable, Fluctuant (with or without any reason), Controlled, Demonstrative.

Character: Timid, Reserved, Shy, Self Conscious, Sensitive, Suspicious, Jealous, Resentful, Quarrelsome, Irritable, Impulsive, Selfish, Dependant, Strict, Fussy, Rigid, Meticulous, Punctual, Excessively tidy.

Habits: Food, Excretory functions, Alcohol, Tobacco, Sleep, and Self-medication.

Energy: Initiative, energetic or sluggish, fatigability.

Fantasy: Extent, Content.

Attitudes and Standards: Moral and Religions.

MENTAL STATUS EXAMINATION

1. Appearance and Behavior

Body build posture, clothes and grooming, facial appearances, Psycho motor behavior, gait, level of activity, movements, interpersonal behavior, attitude towards examiner, level of rapport and eye contact. 

2. Attention and Concentration

Attention: easily aroused and sustained/distractible/preoccupied

Simple tests: digit span test, serial subtraction test, spelling words backwards, reciting the days of the week/month of the year in reverse order. Both accuracy and speed of performance are observed. 

3. Orientation

Awareness of person, place, time, day, date, month, year and social context

4. Perception

• Sensory distortions: Change in intensity, Quality, spatial form.
• Sensory deceptions: illusions, hallucinations, individual senses : hearing vision, smell, touch, taste, pain, deep sensation, vestibular,
• Depersonalization
• Derealization
• Déjà vu
• Jamais vu
• Micropsia
• Macropsia 

5. Mood

Subjective: Patient’s own assessment of his/her mood

Objective: observed by the examiner (Calm, depressed, irritable, anxious, fearful, terrified, angry, happy, elated, euphoric, and apathetic.

Changeability: Monotonic/labile

Appropriateness: appropriate or inappropriate. 

6. Memory

Deficit of Immediate, Recent and Remote 

7. Speech

• Reaction Time: slow/quick, spontaneity – spontaneous/non spontaneous, hesitant.
• Productivity: monosyllable/elaborate/pressured.
• Pitch: Monotonous/whispered loud
• Speed: fast /slow.
• Articulation: Slurring/stammering/dysarthria

8. Thought

Possession: Obsessions and compulsions. 

9. Intelligence

Educational and cultural background, Level of formal education and Self-education, Vocabulary, Interpretation of proverbs, Calculations, General knowledge, etc 

10. Insight and Judgment

Degree of awareness and understanding that the patient has whether he/she is ill

  

Comments and Diagnostic Formulation Provisional Diagnosis:

  

Target Symptoms:

History Taken by:

Date: