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A patient history establishes a baseline and provides clues to the underlying or precipitating cause of the current problem. Remember that the patient may not be a reliable source of information, particularly if he has a mental illness. If possible, verify his responses with family members, friends, or health care personnel. Also check facility records from previous admissions, if possible, and compare his past behavior, symptoms, and circumstances with the current situation.
Explore the patient’s chief complaint, current symptoms, psychiatric history, demographic data, socioeconomic data, cultural and religious beliefs, medication history, and physical illnesses.
❑ Chief complaint. The patient may not voice his chief complaint directly. Instead, you or others may note that he’s having difficulty coping or is exhibiting unusual behavior. If this occurs, determine whether the patient is aware of the problem. When documenting the patient’s response, write it verbatim and enclose it in quotation marks.
❑ Current symptoms. Find out about the onset of symptoms, their severity and persistence, and whether they occurred abruptly or insidiously. Compare the patient’s condition with his normal level of functioning.
❑ Psychiatric history. Discuss past psychiatric disturbances, such as episodes of delusions, violence, depression, attempted suicides, drug or alcohol abuse, and previous psychiatric treatment.
❑ Demographic data. Determine the patient’s age, sex, ethnic origin, primary language, birthplace, religion, and marital status. Use this information to establish a baseline and validate the patient’s record.
❑ Socioeconomic data. Obtain information about the patient’s educational level, housing conditions, income, current employment status, and family, because these data may provide clues to his current problem. Determine current stressors from a holistic perspective.
❑ Cultural and religious beliefs. A patient’s background and values affect his response to illness and his adaptation to care. Certain questions and behaviors considered acceptable in one culture may be inappropriate in another. Determine the extent to which the patient may utilize cultural rituals, treatments, and healing practices.
❑ Medication history. Certain drugs can cause symptoms of mental illness. Review any medications the patient may be taking, including over-the-counter drugs and herbal supplements or remedies, and check for interactions. If he’s taking an antipsychotic, antidepressant, anxiolytic, or antimanic drug, ask if his symptoms have improved, if he’s taking the medication as prescribed, and if he has had any adverse reactions.
❑ Physical illnesses. Find out if the patient has a history of medical disorders that may cause distorted thought processes, disorientation, depression, or other symptoms of mental illness. For instance, does he have a history of renal or hepatic failure, infection, thyroid disease, increased intracranial pressure, or a metabolic disorder? Additionally, has the patient suffered recent head trauma, infection, or physical illness?
Source: Professional Guide to Diseases (Eighth Edition), 2005
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