HISTORY TAKING SCHEME IN PSYCHIATRY

1.  Name, age, sex, address, marital status, religion, occupation, income.

2.  Information obtained from– name, relationship (duration of relationship).

3.  History – adequacy, reliability.

4.  Chief Complaints mention – Duration of illness

i)                                                                      – mode of onset

ii)                                                                     – episode

iii)                                                                    – precipitating factor (if any)

5.  History of present illness (include negative history in the later part)

6.  History of past illness – psychiatric -     Medical

7.  Family history: Parents, sibling, age, marital status, relationship. Family income, social status. Family history of mental illness, substance use disorder.

8.  Personal history: Early development (pre-natal). Childhood – Physical illness. Mental retardation Psychiatric disorder Schooling – when started & ended. Performance, peer relation, Behaviour problems. Marital status Occupation.

IncomeSubstance use disorder. Relationship with spouse, workmate, others Sexual history, menstrual history. Number children & related history

9.  Premorbid Personality

To assess ask about – relationship, leisure (hobbies), Predominant character, habits, Attitude & standards (moral).

A.        MENTAL STATUS EXAMINATION

 i)  Appearance and behaviour :

General appearance, rapport, eye to eye contact.

Attitude towards interviewer – Co-operativeness, guarding, hostility, suspiciousness.

Facies (non verbal facial expression) Posture, movement.

Personal grooming & hygiene. Motor activity.

Hallucinatory behaviour.

ii)  speech: Rate, Volume, tone, spontaneity, reaction time, quantity (stammering, stuttering, dysprosody include here)

iii)  Thought:

A.  Form & Stream.

Flight of ideas, paucity of ideas, over abundance of ideas, spontaneity, hesitant thinking Irrelevant, loosening of association, circumstantiality, tangenciality, perseveration, distractibility, blocking, rambling, evative.

Incoherence, clang association, neologism, word salad. (quotation or samples on verbation – to be noted)

B.   Content & Posession.

a)  Pre – occupations - phobias, obsessions, hypochondriasis, illness, overvalued ideas, antisocial urge.

b)  Delusions           - persecution, reference, guilt, grandeur, jealousy, sins etc.

c)  Ideas                   - Reference & influence.

iv)  Mood – Subjective, Objective.

- Consistency, reactivity, appropriateness.

Mood – Prevailing emotional state.

Description – depth, intensity, duration fluctuation

examples of mood – depressed, angry, fearful, anxious, guilt feeling,

expansive, euphoric, proud etc.

Affect – expression & expressibility of patient’s emotion.

Affect may be described as – normal range, constricted blunt or flat.

v)  Perception

a)     Hallucinations & illusions

b)     Depersonalisation & Derealisation

c)     Dreams and fantasies

vi)  Cognitive function

1) Consciousness – Conscious, confused, clouding, delirium, stupor, coma.

2)   Orientation – time – day, date, month, week etc. Place – home, hospital, office, school.

Person – children, spouse, ward staff.

3)   Attention – DF/DB (Digit Span test)

Ask 3/5 item to remember & ask again

Write a sentence and ask to do it e.g. pick up the ball pen.

4)   Concentration – Serial subtraction 100 - 7

40 - 3

- Ask to say days of week] in reverse order month of year

5)   memory – Immediate – DF/DB

ask to memorize

3 different item and ask to repeat of some gap. Spell of a word backwards.

Recent – Breakfast/ lunch/ dinner recent big news

Remote – date of marriage, birthday of children year of graduation.

6)   Abstract thinking – Proverb test 2-3

similarity/Dissimilarity 2-3 Conceptual series completion

vii)  Judgement

i)                 Personal Judgement (Aim in life/future plans)

ii)               Social Judgement (Relation with others/staff/inmates)

iii)              Test Judgement – letter on the road, house on fire, injured child on the road.

viii)  Intelligence – General information

Calculation Psychometry

ix)  Insight – Grade.

B.    General Physical Examination

1.   appearance, built, anaemia, jaundice, cyanosis, oedema, lymphadenopathy, deformities, signs of injury, injection marks etc.

2.   C.V.S

3.   Chest

4. Abdomen

5.    Skeletal system

6.    CNS

C.    Investigation –

Laboratory

Psychometry

D.      Summary

E.      Provisional Diagnosis.

F.      Differential Diagnosis.

G.     Final Diagnosis.

H.      Management.