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Easy
History Taking Technique Using
Life Event Chart
Dr Norzila Zakaria
Universiti Sains Malaysia
Introduction
1
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.
Practical section
Differential Diagnosis:
Provisional Diagnosis:
Medication taken:
Chief Complaint/s: Must be towards the diagnosis you want to sell
Timeline
Symptom
Treatment
Function
(Page 2)
Relevant Past medical History
Family 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)
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
Extract from
family
history/suppor
t
socal history
belief system
(page 5)
Management
Managem
ent
Biological
Investiga
tion
Blood
Verify history from family members and related people (with patients
consent)
Radiological
Pharmacological
Antipsychotic
Antidepressant
Anxiolytic
Sedative hypnotic
Psychoeducation:
10
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.
Tips:
of admission.
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.
Mode of
admission
12
Example 1:
Example 2:
Example 3:
Feeling like getting a heart attack past 2 weeks with 3 visits to the
emergency department
13
14