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HISTORY TAKING PSYCHIATRY (SAMPLE)

My patient ali raza, 17 years of age, male, married for last 1 month having form
al education up to primary, resident of kherpur city was sent to psychiatry depa
rtment Bahawalpur Victoria hospital on 4th April 2010 forcefully by his family m
embers for psychiatric management. He was accompanied by his brother and wife wh
o are reliable source of information. He was admitted with following chief compl
aints.

History of tablet ativan intake 15 days


Sexual dysfunction 15 days
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HOPI
My patient was in state of usual health when 15 days back he became very
aggressive due to a conflict with his brother. He demanded 8 thousand Rs for hi
s pocket money. This demand was not entertained by his brother. He got very angr
y with this refusal and he took 50 tablets ativan 2mg and two bottles of sedativ
e syrup (somonite) to pressurize his brother. As a result he was just sedated an
d was not hospitalized. His family is very disturbed with this behavior and dec
ided to admit him for his psychiatric management.
My patient is also complaints of his sexual dysfunction as he is unable to main
tain his erection he states that he loses his erection as soon as he goes near h
is wife; he also suffers from premature ejaculation and states that somehow if h
e manages to star intercourse he does not last more than two minutes. He avoids
going near his wife and says that he does not find any pleasure in it. He blames
that masturbation and addiction is the main reason for his sexual weakness. His
wife is also not satisfied with his sexual attitude and she also complained him
on this issue as well. There is no h/o of any sort of trauma to geneteria, any
chronic aliment like diabetes or cardiovascular disease or fimily h/o of similar
disease He has been visiting different hakeem for his complaints but has not co
nsulted any doctor for this problem.
PAST PSYCHIATRIC HISTORY:-& previous treatments
My patient also attempted deliberate suicide attempt to pressurize his f
amily to buy him a new motor cycle one year back when he heavily sedated himself
with 80 tablets of Ativan2mg. He also cut his wrist at multiple sites and his n
eck in the center with a blade and was hospitalized for this self harm.
He is a known addict for last 6 years, he started with bhang addiction at the ag
e of 11 due to bad company of his friends who convinced him that it will make h
im relaxed and happy . He took this drug in liquid form mixed with juices and mi
lk for 3 months 2 to 3 times per week.
After 3 months he was introduced with cannabis addiction by the same friends,
he smoked this drug in form of cigarettes and left the bhang addiction as cannab
is gave him more pleasure. He used to smoke 4 to 5 cigarettes daily hiding from
the family. He also started to take locally prepared Alcohol occasionally once o
r twice a week with the cannabis. He took cannabis and alcohol for 6 year.
he also started taking sedatives 4 years back including tablet Ativan 2mg tablet
s along with syrup somonite . He used to take 5-6 tablets and 2-3 table spoons o
f syrup daily for mental relaxation and lack of sleep.
He decided to leave these addictions 5 months back and he managed to qui
t with the help of local doctor who treated him for his addiction. His treatment
continued for one month and was treated on outpatient bases.
PAST MEDICAL & SURIGAL HISTORY:-
He is took medicine for treatment of addiction from a local general practitioner
4 months back
He was also admitted to hospital for self harm when tried suicide attempt one ye
ar back.
He has also consulted doctor for appendicitis and was relived with medication.
There is also H/O of road side accident 5 years back with injuries to leg and hi
ps.
There no h/o of T.B, HTN, asthma or any other chronic illness there is also no h
/o head injury and any major surgeries performed.
FAMILY HISTORY
He was married one month back with his uncle s daughter.
Father name sharif age 70 alive and suffering from respiratory problem having go
od relationship with the patient.
Mother ulfat bb age 60 years housewife having good relation with the son
5 siblings my patient is third no.
There is no history of any psychiatric disorder in the family.
PERSONAL HISTORY
Birth was uncomplicated. No delay in developmental milestones and no early child
hood illness; he started his formal education at age of 8 years and got educati
on up to primary but did not continue his education as he didn t had any interest
in his studies.
During his academic period he was an average student in studies with poor relati
onship with his class mates and teachers, he was not regular in his school and u
sed to run away from the school and preferred to spend time outside the school.
He quit his education in 5th class as he was not interested in studies anymore.
After leaving the school, He has tried 4 to 5 jobs including farming, working at
the factory, working with his brother but did not continue with any of the job
more than 4 months.
He did not adopt any profession afterwards any used to spend all his time witho
ut any work.
He attained puberty at the age of 11 years and had extramarital relationship wit
h male and female sex partners before marriage. He started masturbating at age o
f 12 and used to masturbate 3-4 times daily as he felt pleasure in that.
He is also involved in fights in his city but never had been legally charged.
Present social circumstances
He is living in cemented house having an area of 7 marlas, along with hi
s parents and wife. His two sisters and one younger brother also stay at the sam
e place.
His elder brother is the main bread earner with aggregated monthly incom
e of 15 to 20 thousand.
He is unemployed for last 5 years. He has tried 4 to 5 jobs including fa
rming, working at the factory, working with his brother but did not continue wit
h any of the job.
Pre-morbid personality
He is an extrovert; but has only one sincere friend. He is a very moody
and irritable person person. His mood changes very rapidly, if he is sitting and
smiling the very next minute he is on to fight. He cannot sit and talk for long
time and he is unable to focus attention on one thing. He is not obedient and d
o not act on elders advice. He has a bad company of addicts and likes spends mos
t of time with them avoiding work. He is very stubborn and he has habit to act v
ery aggressively even cut his wrist if his demands are not met.
He does not have close relation with his family except his parents. He h
ad several fights with is elder brother and his wife he even forced their family
to live at separate home. He also had fight with maternal aunty where he was st
aying for work and she refused to keep him at her place. He is very sensitive h
e cannot tolerate criticism and response very aggressively. He is not regular in
offering prayers. He watches movies as a leisure time activity.
Mental State Examination
An Adult male of short height and thin built sitting comfortable in a straight p
osture with no abnormal movements, he is wearing tidy and colorful clothes. He m
akes eye contact and maintains it, it is very difficult to maintain repo due to
frequent irritability.
His talk is normal and coherent. Rate and rhythm is normal but volume is increas
ed when annoyed.
He is very irritable person. His mood fluctuates between irritable and normal ob
jectively but subjectively he claims normal mood.
No formal thought disorder, no delusions, no perceptional disturbance.
He is well oriented in time place and person with good attention and concentrati
on. He can perform seven serial test correctly without delay of recall. Short te
rm and long term memory is intact.
Abstract thinking is present and normal but insight is absent.