HISTORY TAKING IN MENTAL HEALTH
HISTORY TAKING IN MENTAL HEALTH
HISTORY TAKING
DEMOGRAPHIC
DATA
Name:
Age:
Sex:
Address:
Religion:
TYPES OF
ADMISSION
- PLANNED/VOLUNTARY
ADMISSION:
The patient agrees to come to the hospital and he is willing to take
medication. When stable, the patient can be discharged.
- INVOLUNTARY
ADMISSION/COMPULSORY ADMISSION: The patient is not willing to come
to hospital, but he has to be admitted because he is a danger to self,
family and community. Because the patient is forced to come to hospital,
the family should pass through the magistrate to get the detention order
so as to withdraw the patient’s rights temporarily for 2 weeks. The court
order states reasons for admission and the patient should be kept in an
enclosure. If the patient does not recover for 2 weeks, then the detention
is revoked. If the patient recovers before 2 weeks, he should be kept on
the ward until after 2 weeks.
- COURT ORDER ADMISSION: This is where the
patient has committed a crime. If this patient presents with signs of
confusion, for the court to judge him mentally ill, he needs to be
examined thoroughly at the hospital. The patient will be kept in hospital
for a month without medication and when stable a report will be written to
the court. If after a month the patient still shows signs of confusion, he
will be commenced on treatment and when stable a report will be written to
the court.
FAMILY HISTORY
Causes of mental illness can be
familial, medical or social.
- Ask
for the parents of the patient
- What
they do for their living
- Are
they responsible parents
- If
they died, cause of death
- If
they have divorced, causes of divorce
- If they have divorce, have they remarried
and do they have siblings
- How
does the patient relate with the step mother, step father, step brothers
and step sisters
- How
far have the parents gone with their education
- How
is their life style
- How
is the family generally, is it a well up family
- Are
the family members supportive to each other healthy wise, physically,
socially and financially
- Do
they believe in traditional healers, witchcraft or prayers
- Is
there any history of mental illness, epilepsy, sulcide, rejection,
Diabetes mellitus, sickle cell disease, hypertension or heart conditions in the family
PERSONAL HISTORY
- Find
out the condition of the mother to that patient during pregnance, that is
did she take excessive alcohol during pregnancy, any sexual transmitted
diseases or German measles.
- History
of labour, was he delivered at term, was it an instrumental delivery or
C/S
- Did
he cry very well at birth
- How
were his reflexes
- At
what age did he start sitting, standing or talking
- How
was his interaction with the other babies
EDUCATIONAL
HISTORY
- Find
out at what age the patient started school, that is in town, 5 to 7 years
and in the village 8 to years.
- How
was his performance at school
- How
many schools he has attended, intelligence is base on educational
exposure, educational background and educational performance.
- Did
he have lasting relationships at school; a normal person should develop
lasting relationships with others.
EMPLOYMENT
HISTORY
- Find
out if the patient is happy with the job
- How
is his performance at work
- Has
he ever had an award
- How
does he manage stress at work
- How
is his salary, is he happy with the salary
- How
many times has he changed the job
NB- Failure to be satisfied
with the job or salary may lead to mental illness.
SOCIAL HISTORY
- What
does the patient do during his free time
- Does
he take alcohol or smoke, if he smokes, what type of cigarettes
- Does
he have a lot of friends, extreme socialisation or lack of attachment with
others may lead to mental illness.
MARITAL STATUS
- Find
out if the patient is married, if married at what age
- Was
he forced into marriage
- Are
they happy with each other
- Do
they have children
- How
do they relate with each other and with the in laws
- If the patient is divorced, causes of
divorce and if widowed, causes of death of the spouse
MENSTRAL
HISTORY
- Find
out if the patient is still having menses or she reached menopause.
- Moods
associated with menses or menopause may lead to mental disorder
PAST MEDICAL
HISTORY
- Find
out the conditions the patient suffered from before he became ill. For
example, cerebral malaria, meningitis, HIV/AIDS, encephalopathy or any operation
under anaesthesia.
PREMOBID HISTORY (History before he became ill)
- How
did he use to relate with the family and the community
- How
were his sleeping patterns, eating and toilet habits
- How
did he use to manage stress
MENTAL
STATE EXAMINATION
Mental state examination is
done on admission to arrive at the diagnosis and weekly to assess the
effectiveness of the drugs and improvement of the patient. During examination,
the following should be done:
APPEARANCE
- Note
the well being of the patient if he is generally health or physically sick
- Also
note the dressing as too many clothes or poor buttoning of the shirts may
indicate mental disorder
- Assess
if the patient looks tensed up
GENERAL
BEHAVIOUR
- Assess
the psychomotor activities which may be very fast or very slow
- Is
the patient destructive, restless, uncooperative or spitting anyhow
- Is
the patient banging tables in the examination room
- Is
the patient showing interest when he is being talked to
- Assess
for any mannerisms like shaking legs excessively
TALK/SPEECH
- Assess
how the patient talks
- Is
the talk coherent or incoherent
- Is
the patient talking very fact of very slow
- How
is the flow of information
- How
is the torn of the voice, if the tone is very high, it may mean that the
patient is aggressive and if very low, it may mean that the patient is
depressed
MOOD/AFFECT
- Mood
is the inner feeling and affect is what the patient is expressing
- Assess
if the mood is in line with the affect
- If
you can’t tell whether the patient is happy or sad, write blunt.
THOUGHT
PROCESS
The patient presents with
all sorts of delusions like:
- DELLUSSIONS OF GUITY: The patient always
blames himself and this common in depressed patients.
- DELLUSSIONS OF CONTROL: The patient always
feels there is someone who is in control of his life. This is common in
schizophrenic patients.
- GRANDOIS DELLUSSIONS: The May delusions of
being a king or a queen and he behaves like that. However, a schizophrenic
patient will mention of being a king or queen, but he will not behave like
that.
- PARANOID DELLUSSION: The patient is always
be suspicious and thinks someone wants to kill him.
- PERCECUTORY
DELLUSSIONS:
The patient feels unsafe with someone they love most. They think they can
kill them..
PERCEPTUAL
PROCESSES:
The patent exhibits hallucinations that are in form of the 5 senses, that is:
- TACTILE HALLUCINATIONS: The patient feels
insects are moving on his skin. This is common in patients with alcohol
withdraw.
- GUSTATORY/OFFACTORY
HALLUCINATIONS: Gustatory
means taste and olfactory means smell. The patient experiences bad taste
and smell even when something is tasting and smelling nice. This is common
in epileptic patients that are in the aura stage.
- VISSUAL HALLUCINATIONS: The patient
misinterprets what he sees. He can mistake a belt for a snake.
COGNITIVE
ASSESSMENT
- Level of consciousness: Check if the patient
looks confused, sedated or stuparous Check if the patient is rousable by
verbal stimuli or by pain
- Orientation: Check if the patient
is fully oriented to place, person or time.
Place: Where are you today? Or in
what particular building are you?
Time: What is today’s date?
Person:
What is
your name?
- Attention: Assess if the patient
is able to concentrate on one aspect or he easily gets destructed
- Memory: Test for the
following:
Remote
memory:
Check if the patient is able to recall events or information that occurred a
long time ago, that is, years ago
Recent
memory:
Check if the patient is able to recall events or information that occurred the
past few weeks
Immediate
memory: Assess
if the patient is able to recall events or information he has just been exposed
to.
- Judgement: Give the patient a
hypothetical situation and assess how he is going to make judgement. For
example, if his house in which there was k2000 000 and his baby was set on
fire, ask him which one among the two would he rescue first? If he says
money, then judgement poor.
- Insight: Assess if the patient
is aware of his own condition and reasons for admission. So insight may be
lacking, partial or present.
IMPRESSION:
PLAN
OF ACTION:
- Medical management:
- Nursing
management:
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