Psychiatric history
Presenting Complaint
Presenting Complaint: Felt very low. Admitted loss of energy, and suffering from poor sleep, and early morning waking. Also lost interest in previous activities. Mother died last year, and low mood has been present ever since.
Past Psychiatric History: Had an episode of depression two years ago, before that never had any problems. Has felt very unhappy about life, but never considered harming self.
Past Medical History: Never been admitted to hospital for anything. Only GP consultation was about a bad back, three years ago.
Family History: Mother committed suicide, suffered from depression. No one else in family ever had any problems.
Personal History: Never had any problems neonatally/early childhood. Often felt low during secondary school due to bullying, and has been very affected by what people think ever since. Works as a teacher, which can be difficult, especially with difficult students. Very close to family, but struggles to have relationships due to very low self esteem.
Drug History: Previous course of fluoxetine. Felt very anxious, changed to venlafaxin for 6 months. Currently not taking anything. Allergic to penicillin. Doesn't drink, or take any other drugs.
Forensic History: Never been in trouble with police.
This section is used for finding why they got admitted/came into clinic. You then ask a relevant history; for example, a patient who came in feeling "a bit low", you ask about sleep disturbance, loss of interest in activites, precipitating factors, etc - screening for other symptoms of depression.
It is very important, regardless of what condition, to ask about suicide; failure to do so can fail you an osce!
Past Psychiatric History
Next, ask about previous episodes of their illness, and of other psychiatric conditions.
Rather than saying "have you ever had any other psychiatric problems?", try things like "have you ever been admitted to hospital before?", or "have you ever seen your GP about anything?".
Have they ever been sectioned under the Mental Health Act?
Past Medical History
Again, ask questions about previous consultations with health professionals, since patient memory can be bad at remembering previous illness.
Family History
See if there is any history psychiatric illness in the family.
Personal History
This section is basically a "tell me about your life" bit. It lets you get a picture of the patient as a person.
Developmental
Ask about problems in pregnancy or birth. Go through to early childhood and developmental milestones ("did you start walking and talking at normal ages", etc).
Education
Ask how school was, any problems they had, did they have lots of friends, get bullied. Ask when they left, did they go to college/uni. Why did they leave, did they start working?
Work
Cover job history, did they have high job turnover, long periods of unemployment?
Sex & Relationships
Did they ever have any 'unwanted' sexual experiences? (rape, abuse, etc). Have they been able to form good relationships with friends, family, partners. How long has their longest relationship been? Howmany sexual partners you had in the past one year?
Drug History
Medication & Allergies
Focus on previous psychiatric medications, since this will also help highlight gaps in the previous psychiatric history above.
Alcohol
Do they drink? If so, use the alcohol screening tools.
Drugs
Any illegal drugs; if so, what types, how much and how long for.
Forensic History
Have they ever been in trouble with the police, or spent time in prison?