HISTORY TAKING.pptx for psychatric patient

history taking format

1. Topic -HISTORY TAKING

2. HISTORY TAKING INTRODUCTION IT IS THE RECORD OF THE PATIENTS LIFE IT ALLOWS TO UNDERSTAND Who the patient is. Where the patient has come from. Where the patient is likely to go in the future

3. HISTORY TAKING FORMAT IDENTIFICATION DATA NAME – AGE/SEX – FATHER/SPOUSE – ADDRESS – EDUCATION – OCCUPATION – INCOME – MARITAL STATUS – RELIGION – INFORMANT -

4. 1. CHIEF COMPLAINT ( With duration In Chronological Order, In Patients Own Words And Informants Own Words ) 2. HISTORY OF PRESENT ILLNESS DURATION (days/weeks/months/years) : MODE OF ONSET : Abrupt| Acute | Insidious (<48hours|<1week|1-2 weeks within a few weeks) COURSE : Continuous |Episodic |Fluctuating |Improving | Unclear INTENSITY : Same | Increasing| Decreasing PRECIPITATING FACTORS : Yes/No, if yes explain

5. 3. TREATMENT HISTORY DRUGS(name of the drug ,dose ,route , side-effects, if any) : ECT : PSYCHOTHERAPY : FAMILY THERAPY : REHABILITATION : 4. PAST PSYCHIATRIC AND MEDICAL HISTORY NUMBER OF PREVIOUS EPISODES|HOSPITALIZATION(Psychiatric) WITH ONSET AND COURSE : COMPLETE OR INCOMPLETE REMISSION : DURATION OF EACH EPISODES : TREATMENT DETAILS AND ITS SIDE EFFECTS IF ANY : TREATMENT OUTCOME : DETAILS OF ANY PRECIPITATING FACTORS IF PRESENT: SUBSTANCE USE DETAILS :

6. 5. FAMILY HISTORY DESCRIPTION (describe each family member briefly ) : Age, Education, Occupation, Health Status, Relationship with the patient, Age at death, Mode of death 6. PERSONAL HISTORY A. PERINATAL HISTORY ANTENATAL PERIOD : Maternal Infections |Exposure To Radiation| Any Other Check Ups INTRANATAL PERIOD : Type of delivery- normal| Instrumental| Cesearian Any Complications BIRTH : Full Term |Premature |Postmature BIRTH : Immediate |Delayed BIRTH DEFECTS : Yes or No, if yes, specify POSTNATAL COMPLICATION : Cyanosis | Jaundice | Neonatal Infection | Any Other

7. B. CHILDHOOD HISTORY PRIMARY CAREGIVER : FEEDING : Breastfeed| Artificial Mode Of Feeding AGE AT WEANING : DEVELOPMENTAL MILESTONES : Normal | Delayed BEHAVIOUR AND EMOTIONAL PROBLEMS : Thumb Sucking| Stuttering| Head-Banging| Body Rocking| Nail biting| Morbid Fears ILNESS DURING CHILDHOOD : Specifially For CNS Infections| Epilepsy|Neurotic Disorders|Malnutrition C. EDUCATIONAL HISTORY AGE AT BEGINNING OF FORMAL EDUCATION : ACADEMIC PERFORMANCE : EXTRACURRICULAR ACHIEVEMENTS,

8. RELATIONSHIPS WITH PEERS AND TEACHERS : SCHOOL PHOBIA : LOOK FOR CONDUCT DISORDERS,For Example Truancy|Stealing : Yes|No REASON FOR TERMINATION OF STUDIES : D. PLAY HISTORY GAMES PLAYED ( at what stage and with whom) : RELATIONSHIP WITH PLAYMATES : E. EMOTIONAL PROBLEMS DURING ADOLESCENCE Running Away From Home| Delinquency| Smoking| Drug-Taking|Any other (specify)

9. F. PUBERTY AGE AT APPEARANCE OF SECONDARY SEXUAL CHARACTERISTICS : ANXIETY RELATED TO PUBERTY CHANGES : AGE AT MENARCHE : REGULARITY OF CYCLES, DURATION OF FLOW : ABNORMALITIES, If Any ( Menorrhagia, Dysmenorrhea) : G. OBSTETRICAL HISTORY LMP : NUMBER OF CHILDREN : ANY ABNORMALITIES ASSOCIATED WITH PREGNANCY, DELIVERY : TERMINATION OF PREGNANCY, If Any : MENOPAUSE :

10. H. OCCUPATIONAL HISTORY AGE AT STARTING WORK : JOBS HELD IN CHRONOLOGICAL ORDER : REASON FOR CHANGES : CURRENT JOB SATISFACTION : I. SEXUAL AND MARTIAL HISTORY GENOGRAM : TYPE OF MARRIAGE : Self – choice | Arranged DURATION OF MARRIAGE : INTERPERSONAL AND SEXUAL RELATIONS : Satisfactory | Unsatisfactory EXTRAMARTIAL RELATIONSHIP, If Any Specify :

11. J. PREMORBID PERSONALITY INTERPERSONAL RELATIONSHIPS : FAMILY AND SOCIAL RELATIONSHIPS : USE OF LEISURE TIME : PREDOMINANT MOOD : USUAL REACTION TO STRESSFUL EVENTS : ATTITUDE TO SELF AND OTHERS : ATTITUDE TO WORK AND RESPONSIBILITY : RELIGIOUS BELIEFS AND MORAL ATTITUDES : FANTASY LIFE : HABITS EATING PATTERN : ELIMINATION : SLEEP : USE OF DRUGS, TOBACCO, ALCOHOL :

12. SUMMARY The History and information of the patient is collected and the clinician usually then considers any other factors that might be relevant to the particular patient and enquires about them. Although the gathering of the information may follow the flow of the patients thoughts rather than those of the clinician , it is not uncommon for the clinician to record the psychiatric history under headings to make it easier for others who will later read it. Subsequent history taking concentrates on changes in the levels of symptoms and responses to treatment , including possible side efffects

13. CONCLUSIONS A Psychiatric history taking 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