MSE + history

Link up with psychopathology stuff ⇒

History Taking / Psychiatric History

>> introduction

>> explanation with how long itll take

>> proper setting

>> ask open ended questions

>> allow patients to explain is their own words

>> followed by MSE

1.Personal data

Name, age, sex, marital status, education,occupation, address, religion,socio-economic status

date of admission, type of admission, identification marks, income?

2.Informant/Source of referral

Specify name, relationship to patient and your impression of the informant’s reliability, information relevant or not, interest?, lives with patient?

3.Presenting complaint (in patient's AND informant's own words - both recorded)

Onset

Duration

4.History of present illness + Treatment history

mode of Onset - abrupt, acute, insidious -, course: continous, episodic, remitent, - duration, intensity, precipitating factors, associated disturbances

Presenting psychological symptoms

Changes in behaviour and bodily complaints

Their onset ,development in chronological order

Relationship to any stress or life events

Effects on day today functioning.

Associated changes in vegetative functions

Changes of mood

Anxiety

Depressive symptoms

Speech

Behavior

Level of activity

Thinking - preoccupations, worries, abnormal beliefs, obsessional symptoms, abnormal experiences(hallucinations).

5. Family history

In 1st and 2nd degree relatives - detailed relationship (family genogram of 3 generations)

Age , health, type of illness, duration, recovery, treatment

occupation, personality of parents

patients position in sib ship (in chronological order)

age , sex, marital status, occupation, personality and health of sibs

social position of family, family atmosphere and relationships, family support.

6.Personal history + Obs history if female

Early development

Prenatal, natal history

Health/behaviour during childhood (CNS infections?)

Malnuttrition?

Early neurotic traits

Education

Occupation

Marital history

¨Biographical details

¨Health and personality of spouse

¨Quality of relationship

¨Children details age sex personality

¨Relationship problems

7.Past Psychiatric History

Past episodes of illness, dates, duration, nature, treatment received, side effects, degree of recovery (complete or incomplete remission), any precipitating factors.

Stressors -Psychological and or physical 3ps??

8.Past Medical History

Previous hospital admissions, significant illnesses, head injuries

9. Past Surgical history

10. Drug History / substance abuse

11. History of allergies -Food drug or plaster allergy.

12.Psychosexual history

Relationship with opposite sex

Comfort in sexual identity

Sexual knowledge

Puberty

Menarche

Masturbation

Menstruation

Sexual relationships

Satisfaction

Contraception

Pregnancies

13. Forensic history

14. Substance use

History of alcohol,tobacco use

Onset

Duration

Frequency

Amount consumed

Related problems

15. Premorbid personality

How they would describe themselves

Attitudes to others, attitudes to self, mood,

Ask for a description from others who knows the patient well

few or many friends, hobbies, interests, predominant moods e.g. anxious, confident, over confident, pessimistic

sensitive, obsessional, isolated

religious, attitudes towards health and body

fantasy/day dreams?, reaction pattern to stress? habits?

Mental Status Examination

https://www.youtube.com/watch?v=U5KwDgWX8L8 = watch

.................................................................

–General appearance and behaviour and apparent age

–Speech

–Mood

–Thoughts

–Perceptions

–Cognitive functions

–insight

Appearance

Build, demeanour, dress, grooming, hygiene, facial expressions, consciousness level, oddities of movements, gait and posture, eye contact

Genereal (Build, demeanour, dress, grooming, hygiene)

Face (in psychopathology)

Posture and Gait (in psychopathology)

Movement (in psychopatholgy)

Behaviour (in psychopathology)

Behaviour

3 Appropriate or not , motor activity -4 Motor retardation, motor restlessness, agitation

5 Eye contact

2 Accessibility – Readily accessible, Poorly accessible

1 Attitude towards examiner and examination

Co-operative

relaxed

anxious and tensed up

Reticent

Suspicious

Irritable

Hostile

Threatning

over familiar

Disinhibited

over confident

over-bearing,indifferent,apathetic

Speech

Spontaneity, flow

Rate – over talkative , pressure

Quality – relevant , coherent, loosening of association, vague, idiosyncratic thinking, flight of ideas

MOOD

–Subjective and objective assessment of mood

–Appropriate or not

–Lability of mood – rapid changes

–Blunting of mood

–

–Any suicidal ideation

Thoughts

}

disorders of the form of thoughts are:

Pressure of thoughts (speech)

flight of ideas

Poverty of thoughts

Clang association- next sentence is taken from the sound of the last word

Knights move -where there is no connection

Contents of thought

¨Preoccupations

¨Worries

¨Obsessive-compulsive phenomena

¨Suicidal ideas and intentions

¨Hypochondriacal or other morbid ideas

¨Delusional misinterpretations

¨Ideas of reference

Perceptions

Hallucinations – visual, auditory- noises, voices, other hallucinations,

Illusions

Passivity experiences

Depersonalisation and derealisation

Thought insertion

Thought withdrawal ( describe in patients words)

Cognitive functions

Level of consciousness

Orientation – time,place and person

Attention, distractibility

Memory i. Immediate

ii.Short term

iii.Long term

Language functions

Dysarthria, dysphasia, comprehension, writing, naming objects

General information and ability to solve simple arithmetic problems,Judgment

Insight

Patients understanding of illness and problems

Interviewer’s reaction to patient

Physical examination

Investigations

Diagnosis( ICD 10)

Plan of management

ADD FROM THE OTHER BOOK AS WELL AS YOU GO ALONG!!

Notes :

presenting complaint and history of presenting complaint should be in the patients own word but twist it to fit the definition and criteria without directly telling diagnosis eg : low apetite and mood. obsessed with washing hands

Can use psych terms in the MSE and can state important positives and negatives. Avoid psych terms in history unless it's your interpretation.

Each PC and HOPC depends on the case. Will have its particularities. (will learn with learning every case). But in general will have to analyse: definition and criteria analysis. Excluding DDs. Severity. Aetilology. Risk assessment. Precipiating and prolonging and relapse factors. History of eery episode. ETC ETC LEARN FROM HANWELL'S AND OTHER SOURCES BOOK. WHAT GOES IN PC AND HOPC. MAKE LIST AND APPLY FOR EVERY CASE. GENERAL LIST FOR THIS AND APPLYING AND EVERY CASE LEARN FROM CASES ETC.

But generally must follow the long case template structure and method as used in medicine.

Put and learn sinhala to ask for each particularities for the above and see. Like symptom analysis.

Complete psych case like: 1. History 2. MSE 3. Relevant clinical exam (thyroid, features of alcholism) 4. Diagnosis 5. Assessment 6. Management. Remember to exclude organic causes like thyroid, epilepsy, head injury or infection, intoxication etc

Be careful of mixed picture cases eg: PCD with schizophrenia, schizophrenia with depression. Can be DD but also can be a mixed picture as well. Keep in mind. Substance abuse case and self harm case is a bit different but if mixed must combine the two.

Better to ask substance abuse first - because if the case is unclear can be subtsnace abuse. And for that must go detailed and approach PC and HOPC according to the general ist stuff and case specifiic stuff. Subtsnace can be addiction or toxicity or suicidal attempt.

Suicide and self harm case can be after an episode of suicide attempt - then have to ask method and how suicide attempt and approach the case in a different way.

Advice and counselling also needs to be done as part of the management and for that need to learn sinhala of each.

In introductionary details ask about name, age, gender, address, marital status and occupation.

Its better to write the PC at the end after taking history. In patients own words, but matching the lay definition of a disease. In past psyiatric history can use technical terms.

In HPOC ask about ⇒ Referral and reaons for refferal. Stressors and aietolgoical factors (3 ps). Symptomology. And then complications. On functionality etc. Follow up, treatment, compliance, why defaulted treatment? Last clinic follow up? DD? Risk assessment? Interepisodic functioning?

Always ask "when was the last time" eg : when was the last time you took treatment? When was the last time you went clinic. When was the last time you had this etc when describing course of anything.

Common reasons for defaulting treatment? 1. lack of insight 2 accessibility and affordability 3 becoming better 3 depressed etc etc (put sinhala of how to ask these) 4 side effects

If dropped out of school, ask why dropped out? Financial or cause of mental illness etc?

Always exclude organic and physical illness as well.

Why occupation important? To check for complications and to decide treatment must be careful and to do management around occupation. Also some people will have low threshold to admit. Eg: doctors and monks, While others would be managed at home, these people should be admitted to protect reputation etc.

Risk assessment ⇒ 1. risk to self 2 risk to others 3. specific risk eg occupation risk etc (must be able to assess all of these)

Rememeber its the patients story and he ca be lying. etc. So say "he reports" "he claims" "he admits" etc "he states" HE STATES. HE REPORTS.

Have to check whether he did ECT or took clozapine. Sometimes theyll prep the patient and prepare what to tell and what not to tell. and will tell him to say took clozapine but stopped because heart issues etc. Must be able to elicit this from the patient. stopped because of myocarditis!

Can say "he cannot remember exact details but he recalls that etc"

Can also say "I would like to take collateral history from his mother. I would specifically ask about etc" COLLATERAL HISTORY AND WHAT YOU WOULD ASK ABOUT. to clarify, confirm or refute details.

Doubt everything the patient says because can be a lie. take everything with a grain of salt.

Problem in identifying when the delusions and problems began? Even if patient claims it began after X, when asked about symptoms before X might tell there are symptoms. Does this mean the patient is mistaken and he had symptoms and predispositions all along. And that it started before X and X exacebated it? Or does it mean he's right that it started after X but the stuff he says before X is just lies or just delusions and memory deluding?? So can only exactly verify when it all began by asking collateral history like mother will say he refused to go to school when he was young and had these delusions etc

How to ask drinking or addiction history? Must ask and assess the dependancy criteria.bType? Which? What type? How much? How long? Last consumed? Always ask last! And then must conclude whether he consumed alcohol in a dependant or non dependant way. Must not just state it, Must always give evidence from the history. The same goes with isnight. To tell that insight was poor, medicore or excellent etc. Must have that crtieria and rate out of 5. like 3/5 etc

Gange?kudu? Ice? apple? pregab? pethi - cough syrup? cigereete

Forensic history = any contact with police, courts or law enforcement agency Any court summons? If bought by the police with B report (very unlikely for the main exams) then must ask why?

For personal history ask for any confiding relationships?

How to ask family history when there's poor isnight ⇒ does anyone else in the family think they are buddha or has these special visions?

Even in other subjects its useful to state the purpose of history taking and also how many minutes you have so they'll know and will help you with it.

Pc = can say diagnosed with a chronic mental illness. known patient or diagnosed patient with a chronic mental illness presneting with hearing new voices when there's no body. He has been followed up in the psych karapitiya clinic, where he's recieving treatment. He has been complying, His last etc etc

Always find out why right now admission? Very rarely volunteer admission.

MSE is like creating an image for the examiner. As if the examiner doesnt know the patient and you should build the picture in his mind. As if he's a seniour person you're consulting with. And then giving information and they ask and tests!

Present as if he's a seniour person your consulting with, but then answer questions as if dumb and to cover all aspects.

third person vs running vs commanding.

illusion vs delusion!

"I assessed short term memory via the five item recall test. Registration was 4/5 and recall after five minutes was 1/5. He has good intermeidate memory but poor long term memoryt. Couldnt recall etc"

Attention ⇒ digit span test. Serial seven test. Days of the week backwards. First ased the proper order of the weeks.

"I tried to assess his attention via the digit span test -but he found it difficult and also due to the lack of time, i went onto the serial seven test. The patient did not understand what was wanted - probably out of poor cognition skills. So I asked him the days of the weeks backwards. He told me the correct order of the days, with prompting but failed poorly to recite it backwards. I rate his attention as poor "

In spcyhaitry cant rate anything without evidence. But aay why and rate quantiitvaely using a standard test. must say the components of the test and then conclude. Like for insight must state the answers for all questions and then rate insight.

For substance abuse also must rate insight. And must state at which stage he is. Precontemplation or what?

Depednancy criteria and insight and at which stage

Mental illness are classed under section F of ICD 10!