Psychiatry Made
Easy
History Taking Technique Using
Life Event Chart
Dr Norzila Zakaria
Universiti Sains Malaysia
Introduction
1
Taking psychiatry history is not an easy task. Many new students find it difficult to
get important history that lead to a diagnosis. Sometimes they do not know how
to take the important history as the history is too long.
A simplified way to ask history and working towards the diagnosis is shown in this
method.
There are two parts in this method.
History taking template
Life event Chart
Practical section
1.History taking template (page 1)
Name:
Age:
Sex:
Occupational:
Relevant psychiatry history:
Underlying medical problem:
Differential Diagnosis:
Provisional Diagnosis:
Medication taken:
Chief Complaint/s: Must be towards the diagnosis you want to sell
Timeline
Symptom
Treatment
Function
Example of Life Event Chart
(Page 2)
Relevant Past medical History
Past psychiatry History
Family History
Relevant Past Surgical History
Note: *All past medical/ surgical/psychiatry history can be extracted from the mood chart
( page 3)
Relevant Social History
Differential Diagnosis:
Diagnosis
Points For
Point againts
Provisional Diagnosis:
Note: * Family history and social history must be related to the predisposing, precipititating, perpetuating and protective
factors
(page 4)
Analysis of the problem
Provisional
Diagnosis
Predisposing factors
Precipitating factors
Axis I: All diagnostic
categories except
mental retardation
and personality
disorder
Perpetuating factors
Protective factors
Extract from
Axis II: Personality
disorder and mental
retardation
Axis III: General
medical condition;
acute medical
conditions and
physical disorders
Axis IV: Psychosocial
and environmental
factors contributing to
the disorder
Axis V: Global
Asessment of
Functioning
family
history/suppor
t
socal history
belief system
(page 5)
Management
Managem
ent
Biological
Psycho social and spiritual
Investiga
tion
Blood
Verify history from family members and related people (with patients
consent)
Radiological
Review old notes/medical report from previous hospital admissions
Assess support: Family, financial, spiritual and belief system
Treatmen
t
Pharmacological
Antipsychotic
Antidepressant
Anxiolytic
Sedative hypnotic
Other treatment from other
discipline
Psychoeducation:
Important to engage with the patient and family members
Advice on pharmacotherapy:
o side effect /compliance
o drug interaction
o what to do if ran out of medication
o Telefon number to be contacted if emergency (clinic,
emergency department)
Advice on relapse symptoms
o Getting early appoinment/emergency/admission
Referral to other disciplines (medical, surgical etc)
Follow up clinic, rehabilitation, day care activity, transportation assisstance
Referral to social welfare department for financial assistance/ finding job/
assisst in any difficulties
Spiritual advice and discussion
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How to use History Taking Template
It is simple:
Interview your patients , develop rapport and find what is the chief complaint.
Write any of important finding in the respective columns that you have prepared.
At any time you want to know more detail, inform the patient and get the detail.
Record in the area specified.
The concept:
Let the patient talk and get the important points, fit them in the history taking
template accordingly.
Then only clarify and get more detail.
With this method, you will notice that you have improve your interviewing skill
and know where to get more detail information.
Presenting a psychiatry case
It is important that you practice to present the case to make yourself fluent.
Tips:
Use your own script for each section
Example: Introduction
When you present the introduction section, the examiner should get the
overall idea of what is the problem of this patient. It is more or less like the
formulation in short.
I am presenting Mr A who is a 45 years old Malay gentleman, a divorcee
with 5 grown up children, staying with his eldest son. He is not/known to
have psychiatry problem for the past 15 years and currently on Tab. B, Tab
C and Tab D. He is also not/known to have any/several admission to
psychiatry ward due to poor compliance to medication and follow up. He is
also known to have multiple medical problem namely diabetis, heart
disesase and rheumatoid arthritis.
He was admitted one week ago, brought to the casualty department by his
son with chief complaints of not sleeping well for the past one week, being
irritable at home for the past 3 days and aggressive behaviour on the day
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of admission.
Lets analyse this text
Biodata of the
patient is very
important
Possible precipitating
factors: why he is sick
now
This is to show that he is
a known case of chronic
psychiatry problem
Relevant
medical
I am presenting Mr A who is a 45problem
years old Malay gentleman, known to have
psychiatry problem for the past 15 years and currently on Tab. B, Tab C and Tab
D. He is also known to have several admission to psychiatry ward due to poor
compliance to medication and follow up. He is also known to have multiple
medical problem namely diabetis, heart disesase and rheumatoid arthritis.
He was admitted one week ago, brought to the casualty department by his son
with chief complaints of not sleeping well for the past one week, being irritable
and talking to himself for the past 3 days and aggressive behaviour on the day of
admission.
You want o sell
the diagnosis
of....... ?
Mode of
admission
12
Practice and practice
Practice present your patient history, make sure your chief complaint/s is/are
towrads the diagnosis you want to sell
Example 1:
Stripped naked and increase in sexual drive past 2 days
Feeling very energetic past 5 days
Selling a diagnosis of Bipolar disorder in manic state
Example 2:
Feeling sad for the past one 1 month
Frequent awakening for the past 3 days
Intention to die past 2 days
Selling a diagnosis of Major depression with melancholic features
Example 3:
Sudden palpitation without any obvious reasons past 3 months
Feeling like getting a heart attack past 2 weeks with 3 visits to the
emergency department
Selling a diagnosis of panic attack
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Example: History of presenting illness
Mr A was apparently well until about one month ago when he ran out of his
medication. He started to have difficulty in sleeping in which he sometimes woke
up several times at night and worsening for the past one week in which he was
not able to sleep at all. He was also noted to be talking to himself and scolding
his son and grandchildren for no reason. He admitted to hear a female voice
commenting on his life and accusing him as dayus. He was very angry with the
voice and started to become irritable.
On the day of admission he was noted to carry a parang and shouted kalau
berani mari datang, jangan kata aku dayus!, looked very angry and did not
respond to any persuasion by the family members. With the help of several
people, the son managed to restrain him and brought him to the hospital.
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