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Psychiatry Made

Easy
History Taking Technique Using
Life Event Chart

Dr Norzila Zakaria
Universiti Sains Malaysia

Introduction
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Taking psychiatry history is not an easy task. Many new students find it difficult to
get important history that lead to a diagnosis. Sometimes they do not know how
to take the important history as the history is too long.
A simplified way to ask history and working towards the diagnosis is shown in this
method.
There are two parts in this method.

History taking template

Life event Chart

Practical section

1.History taking template (page 1)


Name:
Age:
Sex:
Occupational:
Relevant psychiatry history:
Underlying medical problem:

Differential Diagnosis:
Provisional Diagnosis:

Medication taken:
Chief Complaint/s: Must be towards the diagnosis you want to sell

Timeline

Symptom

Treatment

Function

Example of Life Event Chart

(Page 2)
Relevant Past medical History

Past psychiatry History

Family History

Relevant Past Surgical History

Note: *All past medical/ surgical/psychiatry history can be extracted from the mood chart

( page 3)
Relevant Social History

Differential Diagnosis:
Diagnosis

Points For

Point againts

Provisional Diagnosis:

Note: * Family history and social history must be related to the predisposing, precipititating, perpetuating and protective
factors

(page 4)

Analysis of the problem


Provisional
Diagnosis

Predisposing factors

Precipitating factors

Axis I: All diagnostic


categories except
mental retardation
and personality
disorder

Perpetuating factors

Protective factors

Extract from

Axis II: Personality


disorder and mental
retardation
Axis III: General
medical condition;
acute medical
conditions and
physical disorders
Axis IV: Psychosocial
and environmental
factors contributing to
the disorder
Axis V: Global
Asessment of
Functioning

family
history/suppor
t

socal history

belief system

(page 5)

Management
Managem
ent

Biological

Psycho social and spiritual

Investiga
tion

Blood

Verify history from family members and related people (with patients
consent)

Radiological

Review old notes/medical report from previous hospital admissions


Assess support: Family, financial, spiritual and belief system
Treatmen
t

Pharmacological

Antipsychotic

Antidepressant

Anxiolytic

Sedative hypnotic

Other treatment from other


discipline

Psychoeducation:

Important to engage with the patient and family members


Advice on pharmacotherapy:
o side effect /compliance
o drug interaction
o what to do if ran out of medication
o Telefon number to be contacted if emergency (clinic,
emergency department)
Advice on relapse symptoms
o Getting early appoinment/emergency/admission

Referral to other disciplines (medical, surgical etc)


Follow up clinic, rehabilitation, day care activity, transportation assisstance
Referral to social welfare department for financial assistance/ finding job/
assisst in any difficulties

Spiritual advice and discussion

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How to use History Taking Template


It is simple:
Interview your patients , develop rapport and find what is the chief complaint.
Write any of important finding in the respective columns that you have prepared.
At any time you want to know more detail, inform the patient and get the detail.
Record in the area specified.

The concept:
Let the patient talk and get the important points, fit them in the history taking
template accordingly.
Then only clarify and get more detail.
With this method, you will notice that you have improve your interviewing skill
and know where to get more detail information.

Presenting a psychiatry case


It is important that you practice to present the case to make yourself fluent.

Tips:

Use your own script for each section


Example: Introduction
When you present the introduction section, the examiner should get the
overall idea of what is the problem of this patient. It is more or less like the
formulation in short.
I am presenting Mr A who is a 45 years old Malay gentleman, a divorcee
with 5 grown up children, staying with his eldest son. He is not/known to
have psychiatry problem for the past 15 years and currently on Tab. B, Tab
C and Tab D. He is also not/known to have any/several admission to
psychiatry ward due to poor compliance to medication and follow up. He is
also known to have multiple medical problem namely diabetis, heart
disesase and rheumatoid arthritis.
He was admitted one week ago, brought to the casualty department by his
son with chief complaints of not sleeping well for the past one week, being
irritable at home for the past 3 days and aggressive behaviour on the day
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of admission.

Lets analyse this text

Biodata of the
patient is very
important

Possible precipitating
factors: why he is sick
now
This is to show that he is
a known case of chronic
psychiatry problem

Relevant
medical
I am presenting Mr A who is a 45problem
years old Malay gentleman, known to have
psychiatry problem for the past 15 years and currently on Tab. B, Tab C and Tab
D. He is also known to have several admission to psychiatry ward due to poor
compliance to medication and follow up. He is also known to have multiple
medical problem namely diabetis, heart disesase and rheumatoid arthritis.

He was admitted one week ago, brought to the casualty department by his son
with chief complaints of not sleeping well for the past one week, being irritable
and talking to himself for the past 3 days and aggressive behaviour on the day of
admission.

You want o sell


the diagnosis
of....... ?

Mode of
admission

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Practice and practice


Practice present your patient history, make sure your chief complaint/s is/are
towrads the diagnosis you want to sell

Example 1:

Stripped naked and increase in sexual drive past 2 days

Feeling very energetic past 5 days

Selling a diagnosis of Bipolar disorder in manic state

Example 2:

Feeling sad for the past one 1 month

Frequent awakening for the past 3 days

Intention to die past 2 days

Selling a diagnosis of Major depression with melancholic features

Example 3:

Sudden palpitation without any obvious reasons past 3 months

Feeling like getting a heart attack past 2 weeks with 3 visits to the
emergency department

Selling a diagnosis of panic attack

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Example: History of presenting illness


Mr A was apparently well until about one month ago when he ran out of his
medication. He started to have difficulty in sleeping in which he sometimes woke
up several times at night and worsening for the past one week in which he was
not able to sleep at all. He was also noted to be talking to himself and scolding
his son and grandchildren for no reason. He admitted to hear a female voice
commenting on his life and accusing him as dayus. He was very angry with the
voice and started to become irritable.
On the day of admission he was noted to carry a parang and shouted kalau
berani mari datang, jangan kata aku dayus!, looked very angry and did not
respond to any persuasion by the family members. With the help of several
people, the son managed to restrain him and brought him to the hospital.

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