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Past psychiatric history examples

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Example 4:

Student's report

Lucy has a 4-week history of severe headache. Initially, Lucy reported a disturbance in her vision, saying that she saw "purplish-black colour spots" in her vision. This was followed by the onset of a severe headache located at the right frontal and temporal regions, radiating to the right occipital area. The headache commenced as mild and dull pain then became severe and throbbing in nature. It was worsened by straining and coughing. Lucy likened the pain to "being stabbed and squeezed by someone continuously" and described the headache as the most horrible she had ever had. Lucy's GP prescribed her Panadol. The medication did not help and Lucy started to experience nausea, vomiting, and mild photophobia. She also experienced pain at the nape of her neck.

2 weeks after the headache commenced, Lucy was referred to an ophthalmologist. An angiogram showed signs of venous blockage in the retinal veins. The headache persisted, and 3 weeks after it commenced, Lucy was becoming more worried about it. She was experiencing (4)sleep disturbance, poor appetite and weight loss (she reports losing 5kg over three weeks). At the time, Lucy resigned from work, thinking that her symptoms were stress-related and she probably needed a break. Lucy also sought a second opinion from another GP. A CT scan revealed a tumour in the right frontal lobe, which was causing oedema and a mid-line shift. Lucy was immediately admitted to MMC for biopsy of the tumour.

Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health. Lucy has experienced two nights of restless sleep. She has lost enthusiasm for her usual activities, such as going shopping and taking care of her son. She reports having no energy for maintaining her work or social life. She has also become more irritable and aggressive, which is putting additional pressure on her family. She admits to being preoccupied with thinking about her illness and is having trouble concentrating on daily activities. She reports feeling tired but too scared to sleep for fear that she will not wake in the morning.

In conjunction with her depressive symptoms, Lucy is also experiencing excessive anxiety. Her anxiety is associated with restlessness, tiredness, irritability, insomnia, and difficulty in concentrating. Other symptoms include palpitations, tachycardia and flushing. Lucy expresses concern over the impending biopsy report, due sometime in the next two days, asking, "Am I going to die? Does the tumour mean cancer?" Lucy also expresses concern over her son's welfare while she is hospitalised. In the last month, her fiance and her mother have been looking after both her and her son.

(428 words)

Writing tip:

In reporting past events, your choice of English tense-aspect will allow you to add your perspective on the current relevance of the patient's symptoms, signs, and experiences.

Incorrect use of tenses and time markers impacts on temporal sequences, which influences the logical structure of the text and may even influence clinical interpretations of illness.

In the example shown, note how the history is reported chronologically, starting with an account of most distant past events and culminating in events and circumstances existing in the present time (i.e. at the time of the interview). Note how the tenses shift through the report.

Comment 1

The report commences with an account of events in the past. In the first two paragraphs, events and experiences are predominantly expressed in the past tense. The past tense is used to refer to:

  • Events in the patient's history that occurred prior to the interview and are squarely placed in the past. Although related to the Presenting Complaint, the assumption of relevance to the current presentation is no longer immediate (compare with the use of the present perfect tense, below)

    "Initially, Lucy reported a disturbance in her vision..."

    "Lucy's GP prescribed her Panadol. The medication did not help and Lucy started to experience nausea, vomiting, and mild photophobia."

Comment 2

The report moves closer to present time. In the third paragraph, the present perfect tense predominates.

The present perfect tense is used to refer to events in the patient's history that occurred prior to the interview but still bear current relevance.

  • In the history, you may describe signs and symptoms that began in the past and are still continuing.

    "Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health. She has lost enthusiasm for her usual activities, such as going shopping and taking care of her son."
  • You may describe signs and symptoms that no longer exist but that have an impact still felt in the present (i.e. they were experienced a short time ago)

    "Lucy has experienced two nights of restless sleep."
  • You may describe completed events whose impact remains significant in the present situation.

    "The physician has diagnosed a tumour in Lucy's right frontal lobe."

Comment 3

The final paragraph brings the account of events and experiences into present time.

The simple present tense is used to describe:

  • Events occurring at the time of the interview with the patient, including the patient's verbal reporting

    "Lucy expresses concern..."
  • Habits and permanent states

    "Lucy is a 34 year-old single mother who lives with her fiance and her 5 year-old son."

Comment 4

The progressive tense is used to describe:

  • Temporary states (symptoms/signs) or situations, either in the past or present time:

    "Lucy is experiencing excessive anxiety."

    "Lucy was experiencing sleep disturbance, poor appetite and weight loss."
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