After watching the
Patient Interview
, write the medical history portion of the psychiatric report. The medical history should include the following sections:
- Identification
- Chief Complaint
- History of present illness
- Past psychiatric and medical history
- Family history
- Personal history
- Summation of observations and impressions
- Review of Systems
An example is outlined on page 24 of Kaplan & Sadock’s Synopsis of Psychiatry textbook.
So what’s been happening over the past week or two that prompted you to make this appointment? I’ve been feeling really down and I’m crying over everything, OK? And when did you first begin to have these kind of problems? I’ve been feeling pretty depressed for the past four months. It’s just been the worst year ever. I was laid off and then I wound up losing my job. My mom died and I had to identify her body, which was very traumatic. And I also have a special needs son who is in the hospital for a week, I’m sorry to hear about your mom, that must have been hard. How is your son doing now? Oh, he’s better now. Thanks for asking. He’s autistic and has epilepsy. I feel like I’m always waiting for the next crisis or hospitalization. It just makes me anxious sometimes. Oh, I understand. Being a mother of a special needs child must be challenging at times. I’m glad to hear he’s doing well now. You also mentioned you lost your job. What do you do for a living? I have a bachelor’s in art history and I worked at the museum. I’ve always had a job up till now. So it’s been a big change for me. Yeah, that must be a big change in the dynamic for you and your husband. How long have you been married? We’ve been married ten years. OK, well, I’m glad he’s been a good support for you. I’m just checking. This is your only marriage. Yes. OK, and how would you describe your marriage? You know, we’re a great team. My husband’s a teacher and he’s he’s very supportive. Good. And do you have a lot of friends or other supportive relationships or groups? Uh, not really. I’m not very religious and I don’t belong to any groups or anything. I mean, I have a few friends, but having a special needs child keeps me pretty busy. Yeah, tell me, have you ever had symptoms like this before? Yes, I had postpartum depression after my son was born. Otherwise, I’ve always been able to manage. But lately, everything has been building up and I’m just not coping very well. I feel like I cry over every little thing. Well, when you’ve had depression before, did you see a therapist or take any medication need to be hospitalized for mental health? Yes, I took Paxil and I saw a therapist for about a year, but I never needed to be in the hospital. OK. Was that helpful for you? Yes. I think things gradually got better as I learned how to handle the stress of being a mother of a special needs child. Good. What about your mental health in general? Do you take any other medications? Yes, I have high blood pressure and I take lisinopril. OK. Do you have any allergies to foods or medications and have you had any surgeries, no allergies? I had a C-section with my son, but that’s the only surgery. OK, well, it sounds like you’ve been pretty healthy, except for the blood pressure. I’d like to ask you more about how you’re feeling now. You’ve been feeling depressed for four months. How has this affected your energy? Yes, I feel like I sleep all the time, but I’m still tired. OK, so you’re sleeping more than normal. But what about motivation? Do you feel less motivated to do things you normally do? Yes, I thought it was because I’ve been so tired, but I just can’t seem to even start doing anything, dishes are piling up in the laundry needs to be done. And I’m not working right now. So there’s no reason to be behind on any of these things. But I just look at the mess and I can’t get up the energy to start doing it. And then I feel guilty for just sitting around doing nothing. I see. That sounds like you have no motivation and you’re feeling overwhelmed and guilty. It must be very frustrating for you. It sounds like it might be making you feel worse. Let me ask you, how’s your appetite? Most days I don’t even feel like eating. I think I’ve lost some weight, but I haven’t checked, OK? Have you had any thoughts about hurting yourself or anyone else? That day, the day my son was in the hospital, I thought it might have given him the wrong dose of his seizure medication and I I felt like it could have been my fault that he was in the hospital. And I I thought about taking pills. I was in a really bad place that day.
My husband made me feel better. He made me realize that I’ve been giving in this medication every day for years. And I probably was just worrying about our son and and feeling guilty. And that’s not even why my son was admitted anyway. He had an allergic reaction. So I know I didn’t do anything wrong. Yeah. Look, feelings of guilt are part of the symptoms of depression. So it makes sense that you are feeling guilt even though, you know, an allergic reaction couldn’t have been your fault. Your husband sounds like he’s a supportive spouse, so I’m glad you have them. Have you had any other thoughts of suicide or hurting yourself? No, I, I know that I, I couldn’t do that to my family, but that made me realize how bad the depression was getting in that I really need to get help.
I’m OK, I’m OK, I’m just I’m just feeling really overwhelmed, yeah, it’s OK. I’m certainly glad you were able to recognize that you need help and you’re here today. We’re definitely going to be able to recommend some therapy and treatment to help you start feeling better. I understand that you’re feeling overwhelmed, but this is what we do here and you’ve come to the right place. Do you feel like you’re ready for a few more questions? Yes, I’m I’m good. OK, has anyone in your family ever had psychiatric diagnosis? My mother also had depression. I think she took medication for it, but otherwise, no. OK, I’m looking at your intake form and it looks like you checked no to all of these. But I’m going to double check and ask you if you’re having any problems with various parts of your body moving from your head to your toes. Have you had any fatigue or weight loss? No. Do you have any problems with headaches, seizures, vision or hearing, smelling or taste throat problems or any thyroid problems? No. Any problems with your heart or lungs, like shortness of breath or coughing? Uh, problems with your stomach, bowels or urination? No. Any problems trying to move your arms or legs? I don’t think so. Joint problems or problems walking and. No. Any rashes? No. Any problems with seizures, numbness or tingling? Uh, have you noticed any bruising or bleeding? Uh, overall, I’m feeling OK today. Good. I’m glad to hear that. Now we’re going to talk a little bit about your background. Can you tell me a bit about where and how you grew up? I was born and raised here with both my parents. And I have a brother who’s two years younger than me. And how would you describe your parents and childhood? Um, my parents were loving. I had a pretty good childhood. I guess lots of friends did pretty well in school. How would your parents react when you got into trouble? I really got into trouble, but they would just ground me. So no spanking or abuse of any kind? No, no, nothing like that. OK, what about school? Were there any problems with bullying or did you have any struggles with low self-esteem? Not really. I was a star student, pretty active in sports. I had a lot of friends. Good. And you never had any legal problems either? No. So just a few last questions about tobacco, alcohol and drugs. Do you use any now or have you ever taken any in the past? I drink wine and I use marijuana edibles occasionally, but I’ve never smoked cigarettes or used any other drugs. OK, well, I think we’ve covered everything unless there’s anything else you want to add. No, I think I’ve told you everything about me. OK, good. Next, we’ll talk about a treatment plan for you.
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