Past Medical Illness

by Helen Farrell, MD

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    00:00 In terms of past medical illness, you want to also explore what their childhood was like any illnesses in childhood. Were they sickly, was anyone in their family is sickly? You want to know about any kind of anxiety disorders or previous depressions. Have they ever been treated before with psychiatric medications? Take a look at their past medical records and you’re looking for any patterns of seeing a doctor frequently, any patterns of having work-ups that were actually reassuring that showed normal results and you want to also be attuned to what kind of advice the patient has been given before and if they followed up with care. Ask about compliance and do a systematic evaluation of your patient. Ask about their family history for a few things to note that you want to ask about, in addition ask about their social history so they could have stress for any number of these reasons and you really want to explore this in a comfortable, relaxed way with your patient where they feel non-confronted and as if you’re being non-judgmental.

    01:07 During the physical exam, you should definitely screen for other medical diseases, take vital signs, look for a baseline from your patient in terms of how they do when they’re at their best.

    01:18 Doing a thorough physical exam will reassure your patient that you’re taking them seriously and it also provides you the opportunity to screen for medical causes of their symptoms and you should also include in your physical exam a complete neurological examination. Make sure to get vital signs and go through the entire cranial nerve exam as well as multiple organ systems.

    01:43 When everything is reassuring and you find no focal neurological or systemic deficits, you want to be careful about doing ancillary testing especially if your review of medical records show that this patient already had a thorough work-up with lots of expensive testing that was all normal and reassuring. So you want to be careful not to redo or overdo things that might not lead towards any other answers when things have been, again, reassuring up until this point.

    02:13 So, you want to be a bit careful about your testing. Be attuned to the fact that even normal lab results may not quite reassure your patient so you want to stay open and ask them what their concerns are, what their fears are because you really want to help the patient build on their strengths and reassure them from a point where they’re ready to hear it and also set up a monitoring program, maybe frequent checks with the primary care doctor because this is something that will help the patient feel listened to and as if they’re going to have followup and somebody who’s going to be caring for them and taking their illness seriously. One of the things a psychiatrist can do when it gets to the point that they are involved is actually named the illness. Okay, so you don’t want to debate with the patient whether or not they’re having symptoms.

    03:08 Acknowledge that they have symptoms and really name what’s happening, explain that while there’s no evidence of a life-threatening illness, they do have described symptoms and that you are going to be attentive to them. Patients feel better when they can actually put a name to what they’re experiencing but sometimes a psychiatric diagnosis will serve no purpose and it will only incite the patient and can be detrimental to their ongoing health. So patients diagnosed with a psychiatric illness can be informed that their condition is likely treatable and you can reassure them this way. Tell them that they may be also experiencing something comorbid like anxiety or depression and that there are in fact ways to approach that and be prepared, though, as a doctor that your patient might get defensive with you. So that’s a summary of the history and evolvement of somatization and somatoform disorders. You know a little bit about diagnosis, you know a little bit about the history and also controversies surrounding the diagnosis and how to approach the management of your patient while being very attuned to listening to their physical complaints and ruling out general medical conditions.

    About the Lecture

    The lecture Past Medical Illness by Helen Farrell, MD is from the course Dissociative Disorders.

    Included Quiz Questions

    1. Similar symptoms in neighbors
    2. Parental care during childhood
    3. Lifetime psychiatry symptoms
    4. Prior treatment with any psychotropic agents
    5. Past medical records - any pattern of suspected ailments that were not confirmed
    1. A thorough physical examination
    2. Referring the patient to another physician
    3. Try to convince the patient that their symptoms are psychiatric in origin
    4. A diagnosis of the specific psychiatric illness should be made first
    5. Immediate dismissal of the symptoms as non-life-threatening

    Author of lecture Past Medical Illness

     Helen Farrell, MD

    Helen Farrell, MD

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