History Taking And History Taking And Mental State Mental State ExaminationExamination

Dr Sharmi Dr Sharmi BhattacharyyaBhattacharyya

Introduce yourself Introduce yourself Explain the purpose and approx how Explain the purpose and approx how

long it will takelong it will takeStart with open questionsStart with open questionsNever hurry a patient – try to be Never hurry a patient – try to be

empathic and listenempathic and listenYou might need an informant ( ask You might need an informant ( ask

patients permission )patients permission )

SOCIO DEMOGRAPHIC DETAILSOCIO DEMOGRAPHIC DETAIL

NameNameAgeAgeDOB DOB Address Address Occupation Occupation Marital statusMarital status

PRESENTING COMPLAINTSPRESENTING COMPLAINTS

Should always be in the patient’s Should always be in the patient’s own wordsown words

H/O PRESENTING C/OH/O PRESENTING C/O

Reason for referral:Reason for referral:

Referred by..Referred by..

What are the main problems?What are the main problems?

Which of these are the worst? Which of these are the worst?

How has that affected you? How has that affected you?

Any precipitating factors Any precipitating factors

When did you last feel well?When did you last feel well?

Obtain a clear Obtain a clear chronological accountchronological account of symptoms ( e.g. depression, of symptoms ( e.g. depression, psychosis) and the effects of these psychosis) and the effects of these symptoms on behavioursymptoms on behaviour

PAST PSYCHIATRIC PAST PSYCHIATRIC HISTORYHISTORY11

In the past have you ever had In the past have you ever had problems with your mental health / problems with your mental health / ‘nerves’/ depression. ‘nerves’/ depression.

Have you ever seen a psychiatrist Have you ever seen a psychiatrist before?before?

PAST PSYCHIATRIC PAST PSYCHIATRIC HISTORYHISTORY22

Have you ever been admitted to a Have you ever been admitted to a psychiatric hospital? psychiatric hospital?

What treatments have you had? What treatments have you had? Has there ever been a time that you Has there ever been a time that you

felt completely well?felt completely well?

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

Do you have or had any problems Do you have or had any problems with your physical health? with your physical health?

Have you ever had any operations or Have you ever had any operations or been in hospital?been in hospital?

CURRENT MEDICATIONSCURRENT MEDICATIONS

What medications do you take What medications do you take regularly and since when? regularly and since when?

What medications have you had in What medications have you had in the past?the past?

FAMILY HISTORYFAMILY HISTORY

Are your parents still living? Are they Are your parents still living? Are they well?well?

Do you mind me asking how they died? Do you mind me asking how they died? What did your parents do? What did your parents do? Do you have any brothers or sisters? Are Do you have any brothers or sisters? Are

you close to them?you close to them?As far as you know, has anyone in your As far as you know, has anyone in your

family ever had problems with their family ever had problems with their mental health?mental health?

PERSONAL HISTORYPERSONAL HISTORY11

Infancy and early childhoodInfancy and early childhood

Where were you born? Where were you born? Where did you grow up? Where did you grow up? As far as you know, was your As far as you know, was your

mother’s pregnancy and delivery mother’s pregnancy and delivery normal? normal?

PERSONAL HISTORYPERSONAL HISTORY22

If not, were there any problems If not, were there any problems around the time of your birth? around the time of your birth?

Did you have any serious illnesses as Did you have any serious illnesses as a young child? a young child?

Were you walking and talking at the Were you walking and talking at the correct times? correct times?

PERSONAL HISTORY PERSONAL HISTORY 33

Adolescence and educationAdolescence and education

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

PERSONAL HISTORY PERSONAL HISTORY 33

Did you have many friends at school? Did you have many friends at school? Still in contact?Still in contact?

When did you finish school ? When did you finish school ? Qualifications? Qualifications?

Were you ever in trouble at school? Were you ever in trouble at school? ever expelled or suspended? Bullied? ever expelled or suspended? Bullied?

PERSONAL HISTORY PERSONAL HISTORY 44

What did you do after finishing What did you do after finishing school?school?

Occupational recordOccupational recordSexual development, Sexual development, Relationships and marriageRelationships and marriageDo you have any children? How old Do you have any children? How old

are they?are they?

PERSONAL HISTORYPERSONAL HISTORY55

Present social circumstancesPresent social circumstancesWho lives at home with you now? Who lives at home with you now? Do you have any worries about debt Do you have any worries about debt

or money in general? or money in general? Do you have friends or family who Do you have friends or family who

live nearby?live nearby?

PREMORBID PREMORBID PERSONALITYPERSONALITY11

Before all this happened, how would Before all this happened, how would you describe yourself? you describe yourself?

How would other people describe you? How would other people describe you? When you find yourself in difficult When you find yourself in difficult

situations, how do you cope? situations, how do you cope? What sort of things do you like to do to What sort of things do you like to do to

relax? relax?

PREMORBID PREMORBID PERSONALITYPERSONALITY22

Do you have any hobbies? Do you have any hobbies? Do you like to be around other people Do you like to be around other people

or do you prefer your own company? or do you prefer your own company? Are you religious?Are you religious?Do you have any ambitions or plans?Do you have any ambitions or plans?

ALCOHOL AND DRUG ALCOHOL AND DRUG HISTORY HISTORY

Do you smoke? How many? Since Do you smoke? How many? Since when?when?

Do you take a drink? Do you take a drink? How much do you drink? How much do you drink? Have you been drinking any more or Have you been drinking any more or

less than normal recently? less than normal recently? Have you ever taken drugs? Tell me Have you ever taken drugs? Tell me

more about that. more about that.

FORENSICFORENSIC HISTORY HISTORY

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

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MENTAL STATE MENTAL STATE EXAMINATIONEXAMINATION

APPEARANCE, ATTITUDE AND APPEARANCE, ATTITUDE AND BEHAVIOURBEHAVIOUR11

Describe appearance:Describe appearance:Body habitus; prominent physical Body habitus; prominent physical

characteristics: tattoos, scars, needle characteristics: tattoos, scars, needle sites; grooming and attire sites; grooming and attire

Level of consciousness, apparent Level of consciousness, apparent age, position and posture, eye age, position and posture, eye contact, facial expressions,rapportcontact, facial expressions,rapport

APPEARANCE, ATTITUDE AND APPEARANCE, ATTITUDE AND BEHAVIOURBEHAVIOUR22

Describe attitude:Describe attitude:Degree and type of co-Degree and type of co-

cooperativeness, resistancecooperativeness, resistance

Describe activity:Describe activity:Voluntary movements and their Voluntary movements and their

intensity, involuntary movements intensity, involuntary movements Automatic movements, Tics, Automatic movements, Tics,

mannerisms, compulsions mannerisms, compulsions

SPEECH AND LANGUAGESPEECH AND LANGUAGE

Assess for:Assess for:Fluency of speech (rate and volume)Fluency of speech (rate and volume)RepetitionRepetitionContent of speechContent of speech

MOOD AND AFFECTMOOD AND AFFECT

Describe predominant mood in Describe predominant mood in patients own wordspatients own words

Associated biological symptoms and Associated biological symptoms and suicidality or homicidalitysuicidality or homicidality

Describe affect and reactivityDescribe affect and reactivity

THOUGHT THOUGHT

DESCRIBE FORM OF THOUGHT:DESCRIBE FORM OF THOUGHT:

Degree of connectedness (loose Degree of connectedness (loose associations, tangentiality, etc.)associations, tangentiality, etc.)

Presence of peculiarities (clang Presence of peculiarities (clang associations, blocking, neologisms, associations, blocking, neologisms, etc.)etc.)

THOUGHT CONTENTTHOUGHT CONTENT11

Describe thought content: Describe thought content: Predominant topic or issues; Predominant topic or issues; Preoccupations, ruminations, Preoccupations, ruminations, obsessions; Suicidal or homicidal obsessions; Suicidal or homicidal ideation; Phobias.ideation; Phobias.

THOUGHT CONTENTTHOUGHT CONTENT22

ABNORMAL BELIEFS:ABNORMAL BELIEFS:Describe any delusions, thought Describe any delusions, thought

interference, reference or interference, reference or persecution, control or passivity persecution, control or passivity phenomenon, nihilistic or grandiose phenomenon, nihilistic or grandiose ideas/ delusionsideas/ delusions

PERCEPTUAL PERCEPTUAL ABNORMALITIESABNORMALITIES

Illusions Illusions Hallucinations- sensory experience Hallucinations- sensory experience

in the absence of a stimulus-various in the absence of a stimulus-various types ( auditory, visual, gustatory, types ( auditory, visual, gustatory, tactile).tactile).

COGNITIONCOGNITION USUALLY MMSE WOULD DOUSUALLY MMSE WOULD DO

GGeneral: Alertness and Co-operationeneral: Alertness and Co-operation[STM: Name, Address, Flower to [STM: Name, Address, Flower to

remember]remember]OOrientation: Time and Placerientation: Time and PlaceAAttention: WORLD backwards and ttention: WORLD backwards and

Serial SevensSerial SevensLLanguage: Naming and Repetitionanguage: Naming and Repetition

COGNITIONCOGNITION USUALLY MMSE WOULD DOUSUALLY MMSE WOULD DO

CCalculation: Division and Subtractionalculation: Division and SubtractionRRight Hemisphere Function: ight Hemisphere Function:

Intersecting pentagons and Clock-faceIntersecting pentagons and Clock-faceAAbstraction: Proverbs and Similaritiesbstraction: Proverbs and SimilaritiesMMemory: STM and Long-term memoryemory: STM and Long-term memoryPPraxis: Wave good-bye and Comb hairraxis: Wave good-bye and Comb hair

INSIGHT AND JUDGEMENTINSIGHT AND JUDGEMENT

Awareness of disease:Awareness of disease: Do you consider that you are ill in any way? Do you consider that you are ill in any way?

Why have you come into hospital? Do you Why have you come into hospital? Do you have a physical or a mental illness? If you have a physical or a mental illness? If you have a mental illness, what is it?have a mental illness, what is it?

Correct labelling of abnormality:Correct labelling of abnormality: You described several You described several

symptoms…..namely….symptoms…..namely…. What is your explanation of these What is your explanation of these

experiences?experiences?

Willingness to take treatmentWillingness to take treatment::How do you feel about being in How do you feel about being in

hospital…..? Coming to the clinic….? hospital…..? Coming to the clinic….? How do you feel about taking How do you feel about taking medication? Has the medication medication? Has the medication been helpful? Have any other been helpful? Have any other treatments been helpful? Do you treatments been helpful? Do you think that medication helps you to think that medication helps you to remain well?remain well?  

Remember to always do aRemember to always do a PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

!!!! !!!!General observations: Vital signs: HR, General observations: Vital signs: HR,

BP, RR, Temp: Autonomic arousal, BP, RR, Temp: Autonomic arousal, tremor, sweating etc.tremor, sweating etc.

Important features: scars, tattoos, Important features: scars, tattoos, signs of liver disease, signs of thyroid signs of liver disease, signs of thyroid or Cushing’s disease, etc., Specific or Cushing’s disease, etc., Specific CVS, RS, GI, and CNS examination CVS, RS, GI, and CNS examination findings and important negative findings and important negative findingsfindings