History Taking
History Taking
History Taking
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د کنفرانس موضوع - :تاریخچه
رهنما استاد - :ترینر متخصص ډاکتر سید عبداالحد قریشی
د کنفرانس وړاندي کوونکي - :محمد سرور -د اول کال ترینی
صنف - :اول
روغتون - :روانی روغتیا
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Outlines:
1- Parts of the initial psychiatric interview
2- Elements of initial psychiatric interview
3- History taking and parts of history
Identifying data
Source and reliability
Chief complaints
History of present illness
Past psychiatric history
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Substance ,Use, Abuse, and , Addiction
Past medical history
Family history
Developmental and social history
Review of system
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History-Taking:
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Parts of the initial Psychiatric Interview :
1- Identifying data
2- Source and reliability
3- Chief Complaint
4- Present illness
5- Past Psychiatric History
6- Substance use and abuse
7- Past medical history
8- Family history
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9- Developmental and Social history
10- Review of System
11- Mental State Examination
12- Physical Examination
13- Formulation
14- DSM-5- Diagnosis
15- Treatment plan
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Elements of initial Psychiatric Interview:
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Parts of History:
1- Identifying- Data
Name
F/Name
Age
Sex
Marital State
Religion
Occupation
Referral Source
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2- Source and Reliability سرچینه او ډاډتوب
3-Chief/Presenting Complaints د ناروغ عمده شکایات
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4- History of Present illness د اوسنۍ ناروغۍ تاریخچه
Chrono-logical order زمانی ترتیب
Symptom definition, duration, and onset
Definition of symptoms by patient
Predisposing factors
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Precipitating factors (Triggering factors) تسریع کوونکی فکتورونه
Perpetuating factors دوامداره کوونکی عوامل
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The essential questions to be answered in the history of present
illness include
What(symptoms)
How much(severity)
How long
And associated factors
Psychiatric review of system ترڅو د ناروغۍ تشخیص صحیح او یا رد کړو
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5-Past Psychiatric history:
Past Psychiatric illnesses and its duration
Symptoms onset condition
Triggering factors
Treatment place
Treatment duration
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Treatment types
ECT
Alternative therapy
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Response to treatment and form of treatment like,
Outpatient
Day Patient
Inpatient
Side effects of treatment
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6- Substance Use, Abuse , and Addiction:
A careful review of substance use, abuse , and addiction is essential to
the psychiatric interview
This information may be difficult for the patient to discuss
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Substance have been used like, alcohol, drugs
Routes of use
Oral
Snorting
IV
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7- Past medical history:
Past medical illnesses
Past operation
Hospitalization
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Mimic of psychiatric disorder( hyperthyroidism resembling of Anxiety
disorder)
Influence the choice of treatment of psychiatric disorder(renal
disorders and the use of lithium carbonate)
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8- Family history:
Familial disease (Genetic predisposition)
Family background
Educational state
Social status
Family history of sucide is a significant risk factor for suicidal behavior
in the patient
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Medical illnesses also present in the patient family history,
May be also important in both the diagnosis and treatment of the
patient
Eg, diabetes or hyperlipidemia affecting the choice of antipsychotic……..
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The family history is important in identifying potential support as well
as stressor for the patient
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9- Developmental and social history:
Prenatal or birthing history and developmental milestones
Childhood history
Number and quality of friendships
School history
Behavioral problems at school
Childhood physical and sexual abuse
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Work history
Types of jobs
Performance at job
Reason for changing jobs
And current work status
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Marriage and relationship history
Relationships with all family members
Legal history
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10-Review of systems :
Generally the review of system is organized by the major systems of the
body.
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Thanks a million
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