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This article mainly covers the initial assessment history taking of a patient presenting for the first time with a new complaint.
In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions. Some of these questions are quite specific, such as, "How old are you?" and others are more open, such as, "How have you been feeling lately?" Although the structure of the interview may appear disjointed, the end result is usually under a set of headings which have a worldwide similarity.
The basic details of who the patient is are collected. This includes their age, sex, educational status, religious, occupation, relationship status, address and contact details. This serves several purposes. Firstly, it is necessary information for administrative purposes and for this reason some of this is often taken by clerks. Secondly, the questions are largely non threatening and provide a gentle introduction into the meeting of patient and clinician. Thirdly, it provides a format for individual introduction suitable to the culture. Thus the clinician may start by introducing themselves and then move on to these questions. This initial structure can provide a sense of familiarity for the patient who is stressed about what is happening.
The next step is to determine why the patient is there. How did they get to be in the interview? Were they referred by someone (such as another clinician, a relative or friend, or by the police or the courts) or did they come looking for help? If they were referred by someone then what was that person's reason for the referral. Often such information is provided in a referral letter or by an earlier phone call.
The clinician next tries to clarify what are the main problems that have brought the patient to be there. Some of this may have already been achieved in the previous section. The patient may have more than one problem and these may be related, such as posttraumatic stress disorder and alcohol abuse or seemingly unrelated, such as panic disorder and premature ejaculation. The patient is unlikely to present a diagnosis and is more likely to describe the nature of their problems in common language.
The clinician then attempts to obtain a clear description of these problems. When did they start? How did they start, suddenly, slowly or in fits and starts? Have they fluctuated over time? What does the patient describe as the essential features of the complaints? Having developed a hypothesis of what may be the diagnosis, the clinician next looks at symptoms that might confirm this hypothesis or lead them to consider another possibility. Much of the mental process for the clinician is involved in this process of hypothesis testing to arrive at a diagnostic formulation that will form the basis of a management plan. The severity of each complaint is assessed and this may include probing questions on sensitive issues such as suicidal thoughts or sexual difficulties.
This is divided into the psychiatric past history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. The medical past history documents significant illnesses, both past and current, and significant medical events such as head injury, surgery and major illnesses.
Many psychiatric disorders have a geneticGenetics is the science of genes, heredity, and the variation of organisms. Humans began applying knowledge of genetics in prehistory with the domestication and breeding of plants and animals. In modern research, genetics provides important tools in the i component and the biological family history is thus relevant. Clinical experience also suggests that a response to treatment may have a genetic component as well. Thus a patient who presents with clinical depressionIt is common to feel sad, discouraged, or "down" once in a while, and anyone in this state might say they are suffering from depression. But for some people, this mood persists. For depression, or any other condition, to be termed "clinical" it must reach whose mother also suffered from the same disorder and responded well to fluoxetineFluoxetine hydrochloride (brand names include Prozac , Symbyax [compounded with olanzapine, Sarafem , Fontex [Sweden], Fluctine (Austria, Germany)) is an antidepressant drug used medically in the treatment of depression, obsessive-compulsive disorder, bul would indicate that this drug would be more likely to help in the patient's disorder.
Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment. Similar effects are seen with the death of a parent from a protracted illness.
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