HISTROTY TAKING

The interview aims to gather essential information for diagnosis, understand the patient's illness, and build a therapeutic alliance. General advice for the opening includes creating a comfortable atmosphere, introducing oneself, and ensuring privacy. Key aspects involve observing nonverbal behavior, avoiding excessive note-taking, and formulating open-ended questions. Detailed assessments, including familial and personal history, mental state examination, and risk factors, contribute to a comprehensive understanding of the patient’s condition.

• psychosomatic medicine
• patient interview
• mental health assessment
• therapeutic alliance

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1. HISTROTY TAKING HISTROTY TAKING Dr. Ayedh Al- Ghamdi. Psychosomatic Medicine Consultant. Psychosomatic Medicine Unit, Department of Psychiatry King Saud University Medical City

2. AIMS OF THE INTERVIEW: - Obtain the necessary information to make a diagnosis . - Understand the person with the illness. - Understand the circumstances of the patient . - Build a therapeutic alliance (rapport). - Provide the patient with information about the illness , recommendation and prognosis .

3. INTERVIEW OPENING (GENERAL ADVICE): - Put patient at ease . - Introduce yourself and Greet the patient by name - Reassure privacy and confidentiality, separate room. - Suitable distance ( e.g. with geriatric ,with aggressive pt.) - Be supportive, attentive, non judgmental and encouraging.

4. INTERVIEW OPENING (GENERAL ADVICES ): - Explain about yourself ,the purpose of interview and expected time needed . - Observe the patient s nonverbal behavior and Avoid excessive note-taking - With whom you will start ( pt. or his relative ). - Why he come with a relative ? ( psychosis Vs. neurosis ) - Start with open ended questions .

5. M.S.E FAMILY HISTORY :- - Identification data :- (name, age, nationality, sex, marital, education, job, residency) Appearance & behavior Mood (subjective & obj.) Thought ( suicidal , homicidal , overvalued , delusion , obsession .. etc.) Perception Cog. function ( if impaired do MMSE) Insight & judgment Parents (age ,consanguinity, illness) Sibling (age, illness, order of Pt.) +ve Hx of (psych , drug , homicide , suicide ) - Chief complaint * - Source of information - Reliability Do not forget relation bet. Themselves & bet. Pt PERSONAL & SOCIAL HX :- Childhood (preg. Development) Schooling (age, level ,performance , relations ,misconduct) Marital (age, consanguinity, children, relation past & current) Occupation (age, duration , relation , performance) Forensic (arrest, prison & why) Social ( living situation, financial stat , support ) SUMMARY & FORMULATION Current Sx Precipitating F. Brief past psych. Hx Predisposing F. (biopsychosocial) Safety Imp. Point in Tx. H.P.I :- Dissect symptoms (onset , severity ,course) Chick main illness Precipitating & reliving F. Chick for function Any medical intervention (seek medical advice , Mx) Don t forget S.O.A.P S- suicidal & homicidal O- organisity A- addiction P- psychosis Don't forget detail & reason of any (stop of school ,change or quit of job , divorce & other wife's) DDx & Mx: Bio Psychosocial in assessment & treatment Short & long term Tx Be specific ((e.g. I'll start pt on Risperdal 2mg NOT I'll star pt on atypical antipsychotic.)) Education of pt & family PAST HISTORY :- Psychiatric.:- previous episode(reason) , f/u, admission (number, duration ) & Mx (What, dose, response ,S/E) Medical Surgical PRE PRE- -MORBID PERSONALITY MORBID PERSONALITY How described by other? Prevailing mood Social skill Hopes ?impulsivity coping Don't forget (head trauma, epilepsy, thyroid, and Sys. Review)

6. STRUCTURE OF HISTORY : Identification of the Patient: Name, age, sex, marital status, occupation, education, nationality, residency . Referral Source: Brief statement of how the patient came to the clinic and the expectations of the consultation. Chief complaint: Exactly why the patient came to the psychiatrist, preferably in the patient s own words .

7. STRUCTURE OF HISTORY : HPI: - Nature of the symptoms , onset, course, severity, duration, effects on the patient (social life, job, family). - review of the relevant problems, - symptoms not mentioned by the patient (e.g. sleep, appetite, ), - treatment taken so far (nature and effect). - Important ve (e.g. history of mania in depressed patient ) - Suicide ,homicide, substance abuse.

8. STRUCTURE OF HISTORY : Past psychiatric history( admissions, depot injections ,drug level . .etc ) Past medical history . Family history . Personal history. Forensic history . Premorbid personality.

9. Structure of history : Premorbid personality : - Prevailing mood and emotions. - Interpersonal relationships - Moral and religious attitudes and standards. - Reaction to stress (ability to tolerate frustration, pattern of coping strategies). - Personal interests, habits, hobbies and leisure activities. .

10. INTERVIEW SKILLS : -Transition . - Obstructive technique . - Facilitation technique : - Clarification - Empathy .

11. AAYEDH@KSU.EDU.SA Thank you