BRIEF GUIDELINES ON HOW TO TAKE A HISTORY AND PERFORM A MSE

INTERVIEW
Safety comes first Collateral historian Open ended questions

HISTORY
 Demographic details Mode of referral and current treatment.
 Eg. AB, a 30YO U/E Divorced lady. Lives with 8YO Da in council flat. R/B GP due to concern
@ suicidal risk. Complied with fluoxetine last 2 weeks.

PRESENTING COMPLAINT
 ‘shopping list’ & then more detail:
 Includes: mood, risk, anxiety, panic attacks, psychotic sympts, bizarre behaviour, alcohol,
drugs, biological sympts, DVM
 Level of dysf(x) / typical day

HISTORY OF PRESENTING COMPLAINT

Onset & deterioration. Baseline f(x)ing Stresses / ppts

FAMILY HISTORY

PERSONAL HISTORY
 Birth and brought up. Milestones and childhood neurotic traits
 School: behaviour, social relationships, academic achievements
 Occupation: durations and reasons for changes
 Sexual / Relationship history: duration, quality
 Alcohol / Drugs Forensic Hx
 Premorbid personality Current social circumstances

PAST MEDICAL HX Includes OD’s / DSH DRUG TREATMENT

PAST PSYCHIATRIC HX
Ed Psychologists, counsellors, GP, Psychiatrist
Past admissions: status, duration, benefit, diagnosis
Past / Current medical & psychological treatments: compliance, tolerance, duration

MENTAL STATE EXAMINATION

A & B: General appearance Social behaviour Motor behaviour

Speech: rate / quantity / quality / flow

Mood: subjective / objective Biological sympts

Thoughts: Cognitions: past, future, present (esteem, worthless, useless, guilt, hopeless)
Suicidal Ideation eg.‘how bad can you end up feeling?’
Preoccupations, OCD sympts
Psychotic sympts (delusions v overvalued ideas, thought interference, passivity)

Perception: Illusions, hallucinations (all modalities), pseudohallucinations

Cog.F(x): OTPP
Concentration: Serial 7’s, Mths b’wards, ‘WORLD’ b’wards
STM (N&A) / LTM

Insight: COLLATERAL HX PHYSICAL EXAMINATION