Taking the History

by Helen Farrell, MD

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    00:01 Taking the history. Let's look at this in a little bit more detail now.

    00:04 When you're taking a history start with identifying information of the patient such as demographics.

    00:11 Things like their name, address, and age. Then you want to go into their presenting complaint.

    00:17 This should always be in your patient's own words. So, what brought them in to see you today? Take the history of the present illness, their psychiatric history, social and developmental history, past medical and surgical history, medications and allergies, and also their family history.

    00:37 So we've listed here a lot of different types of information you want to include in your history.

    00:43 We'll look at each of these in a little bit more detail in a moment.

    00:46 To summarize, when you're taking the history it is crucial that you're creating that therapeutic alliance with the patient by providing a relaxed and supportive environment, being non-judgemental, comfortable, and being attentive and caring to your patient.

    01:03 That patient needs to feel as if they can trust you and this will foster them in opening up.

    01:09 And also the therapeutic alliance is really critical to gathering the information needed to complete that mental status exam where you're creating a picture of who that patient is.

    01:20 So, looking at things in a little bit more detail now. What do you think is important when you think about that history of presenting illness? So, this is why the patient came to you and that's a great way to lead things off saying, 'So, what brought you in to see me today'? Then, you want to invite the patient to describe a little bit more about the current episode in terms of the symptoms they're experiencing. You also want to know what events were happening in this individual's life that lead up to this present moment when they've come to see you, the psychiatrist. You want to know how their symptoms are affecting their work, their life, their relationships. Also, you want to know about that individual support system.

    02:03 So, do they have one or not? Who's helping them get through this tough time? And you also want to know about physical symptoms because we know there's a huge overlap between our bodies and our minds. So, inquire as to how they're feeling physically at the time of seeing you. Also, you want to know more about this current episode when I encouraged you earlier to ask the patient about symptoms they're experiencing. Here's what I meant.

    02:32 Asking them about vegetative symptoms. These are going to be things like interference with sleep, appetite concentration. You want to know if there are any psychotic symptoms happening.

    02:44 So, things like hearing voices or seeing things. Inquiring if the patient is feeling at all paranoid or out of touch with reality. You want to know how the patient is functioning when they're well.

    02:58 So, what's their baseline? And you also want to know a little bit more about their developmental history. Has this problem ever happened before? Did something happen earlier in their life that could be interfering with their ability to function now? Ask them what their goals are both in seeing you in a short term, and also long term treatments.

    03:19 And you also want to know if there's any evidence for secondary gain and what I mean by that is being attuned when you talk with your patient to trying to identify if somehow they're going to get something out of having an illness.

    03:35 For example, could they be coming to the emergency room asking for admission to a psychiatric unit solely because they're trying to evade homelessness or maybe criminal charges? So, this is something you just want to be attuned to when you are taking your patient's history.

    03:52 And all of these questions should be open ended. So, again, avoiding yes and no questions but rather invite your patient to tell you their story.

    04:03 When you're thinking about the past psychiatric history, there are a lot of things that go into this that you want to ask your patient about.

    04:12 So, you want to ask your patient for example, what's your understanding of your diagnosis? It's amazing how many patients have seen dozens of psychiatrists in my experience and by the time they get to me, they have no clue what their diagnosis is.

    04:29 Some know their symptoms but they've never quite been able to pin point it to a diagnosis.

    04:35 Others do have a good understanding of what type of diagnosis they have and so it's really important to ask your patient, 'What do you understand about your diagnosis' What have you been told before'? And then, you want to go a little bit deeper too.

    04:49 So, ask the patient if they've ever been admitted into a psychiatric unit.

    04:54 Beyond that, ask them a little bit about when they were admitted, why they were admitted, because your approach to the patient is really going to depend on these variables, right? Somebody who's been admitted to psychiatric units repeatedly for suicide attempts is going to be treated in one way with a management plan, as opposed to the patient who's admitted to psychiatric units because of a floored psychotic episode.

    05:20 So, you want to know kind of what triggered these hospitalizations, you want to know where they happened, and you want to know what was both helpful to the patient and harmful to them when they were in the hospital so you can make the best recommendations possible that they'll be most likely to adhere to. And then you also want to know if your patient has any current psychiatric providers, are they seeing a therapist, are they taking medication, and you want to know what their relationship is like to these providers, what's helped them have a good or a bad alliance and how you can help foster a positive relationship with psychiatry. Moving forward, when thinking about the psychiatric history there are a few more specific things you need to ask about. So, you always, always want to ask about safety. So, this includes asking about suicidal and homicidal thoughts.

    06:12 Not only in the present current time but also in the past.

    06:16 If somebody's currently expressing safety concerns, you must dig deeper and ask them, what concerns they're having, whether or not they have a plan to either self-harm or harm somebody else, and whether or not they have an intent to carry through with these plans and the means to do it. You also want to ask about current medications, the doses, the durations of treatment, and whether their response has been good, bad, or indifferent. Also, ask if your patient has a history of having electroconvulsive therapy or ECT, and finally ask what types of out-patient services have been recommended to them in the past and why or why not they followed through with them.

    07:01 In addition, knowing what treatments they prefer and why is important and also, how is your patient's compliance? Asking them a little about what helped them comply with treatment, were there hindrances, whether it was access to care or medication but really invite your patient to be honest about their history in the psychiatry experience and how it's been for them. When exploring substance abuse issues with patients, this is another very critical part of the psychiatric history and it's something that should be approached directly and also, non-confrontationally and non-judgementally.

    07:40 So, ask very clearly what their experience has been with alcohol, tobacco, caffeine, and dig deeper.

    07:47 Ask about frequency of intake, the amount, and what their preferred substance is.

    07:52 Also, be sure to ask about elicit street drugs. In addition, ask about prescriptions and over-the-counter medicines that the patient might be taking.

    08:02 Ask about times where they've become intoxicated, had blackouts, or withdrawals.

    08:07 What their experience was, what they physically endured, and whether or not it lead to an emergency room visit or potentially an intensive care unit visit.

    08:18 You want to ask them if they perceive that they've ever had any problems with substances, especially with drinking. And also whether or not your patient has ever engaged in a rehab or a sober program. When taking the past medical and surgical history, you want to be very thorough here because again, as I've said before, there's a strong overlap between the physical body and the mind. So, you want to know about every medical problem your patient has ever been diagnosed with, any surgery that they've ever had, and you especially want to specifically ask about any head injuries, concussions, loss of consciousness, any seizure disorders, traumatic brain injury, and any kind of infective process like HIV or AIDS. When it comes to the family history, a few things that are really pertinent to ask about are things like psychiatric illness or diagnosis in the family, if there had been any suicide attempts in the family and beyond that, any completed suicides within the family, any episodes of violence, and also, whether or not any members of their family have undergone treatment by a psychiatrist or in the hospital. When it comes to psychiatry we often think many disorders are genetic and they run in families. So, I can't overemphasize enough the importance of taking a good family history. When it comes to the family history, also ask about medications that a family member has used, what their response to treatment has been, and also whether or not a family member has had ECT or electroconvulsive therapy. When it comes to taking a social history, this is really something that sets psychiatry apart from other medical specialties and that you want to take this moment and opportunity to really engage with your patient.

    10:09 So, when you think about that, think about what kind of questions would you want to know about your patient in terms of their background, their family life, and I'll go through a few now that might be on your mind. So, you want to ask, where was your patient born and raised? What was their childhood like? Ask about their mom and dad, who was in the home while they were growing up and what their childhood was like for them, you want to know about that relationship to their early caregivers whether it was good, bad, or neutral, and also, a little bit about their developmental history. So, progression from kindergarten into grade school, high school, college, how far did they go in education, what was their highest level attained, and were there any setbacks during that period, ever being held back in school, any developmental delays, or did your patient meet all of their milestones at the appropriate age.

    11:04 And you also want to ask a little bit about their employment background, what kind of jobs have they held, how long have they had their job, do they like their job? This is really your chance to be curious about your patient.

    11:16 A few other things to consider would be whether or not your patient has ever been married, whether they have children? Ask them what kind of hobbies do they have, what do they enjoy to do, and invite them to really tell you what they have fun with, where they find pleasure in their life and how they seek that out.

    11:33 You want to ask patients about any ownership of guns or weapons.

    11:38 This is very important in terms of when you do their safety assessments.

    11:44 You also want to know about their religious beliefs. Whether or not they have any legal troubles and if so, what has been the extent of their legal trouble with the law? And you also want to ask them a little bit about any history of abuse whether it's physical, emotional, or sexual. Something important to note is when asking your patient about sensitive material, things like history of abuse, history of violence, make sure to be direct.

    12:11 It's really important to keep in mind that if you hesitate or are at all indirect, your patient might be less likely to open up because they're going to feel uncomfortable if they sense your unease. This brings us to the conclusion of the psychiatric history and assessment.

    12:29 This was a broad overview of some of the very important things to consider when taking the history.

    12:35 So, be sure to keep in mind things like making the patient feel comfortable, developing that therapeutic alliance, and also, although this is a psychiatric history, you're really asking your patient about their whole life story and keep that in mind.

    About the Lecture

    The lecture Taking the History by Helen Farrell, MD is from the course Psychiatric Assessment. It contains the following chapters:

    • Psychiatric History
    • History of Substance Abuse
    • Past Medical/Surgical History

    Included Quiz Questions

    1. In the patient’s own words
    2. From the attender of the patient
    3. Previous records from the hospital
    4. By calling the doctor who treated the patient previously
    5. By prompting the patient with medical terminology
    1. What medication was the patient previously on?
    2. What were the events leading up to the present moment?
    3. What is the patient’s support system?
    4. What is the relationship between physical and psychological symptoms?
    5. How have the patient's work and relationships been affected?
    1. "Has anyone in your family been diagnosed with cancer?"
    2. "Are you having problems with your sleep or appetite?"
    3. "Has something like this happened to you before?"
    4. "What's your day like when these things aren't bothering you?"
    5. "Have you heard strange sounds or voices, or seen things that aren't there?"
    1. Preferred substances, frequency of intoxication, withdrawals, and quitting attempts
    2. Suicide attempts when clean
    3. Evidence of secondary gain
    4. Recent history of travel
    5. Previous surgeries
    1. suicide attempts in the family.
    2. head injury/concussion.
    3. seizures.
    4. HIV/AIDS.
    5. traumatic brain injury.
    1. Social history
    2. Family history
    3. Past medical history
    4. Past surgical history
    5. Substance abuse history
    1. Open and direct
    2. Ask open-ended questions indirectly.
    3. Ask the patient to fill up a consent form to provide accurate information.
    4. Request the patient to select among multiple options prepared on a form.
    5. Continuously persuade the patient to answer quickly to obtain the most reliable version of the events.

    Author of lecture Taking the History

     Helen Farrell, MD

    Helen Farrell, MD

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    A Good Lecture With Lecture Notes and Quiz
    By Jacklin G. on 11. August 2018 for Taking the History

    This was a good lecture. I am trying to take all of the Free Classes offered by Lecturio, so as to improve my own health. I appreciate this lecture, because it is offered by an instructor who has a real medical background. It is very easy to follow Dr. Helen Farrell's line of reasoning. The main points are also fairly easy for me to follow on the screen, because you provide these lecture notes to the student. The quiz helps me to see how well I grasp the information you explain in the lecture. Thank you so much for this offer.