How is the history of the present illness elicited during the Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Answer

Answer

This is the main part of the interview because there are no specific elements that will lead to the diagnosis and ultimately treatment besides the interview. An exact history allows one to gather basic information along with specific symptoms including timing in the patient's life to allow the healthcare provider to take care of the whole patient.

The important part of taking a history of present illness is listening. One should have an organized format but not too rigid in administering the examination. For example, if asking about medication allergies and the patient brings up problems with alcohol, follow the patients lead and obtain information regarding the new data but then guide the patient back to the interview to allow all information to be gathered. Without a specific format, important information may be missed. However, the order in which information is gathered may be dynamic and fluid based upon discoverin essential information that a patient may provide. 

Remember to include both pertinent positives and negatives because these could be important aspects in determining diagnosis and treatment in complicated cases. Record important life events to complete this part of the evaluation, and this may help in establishing rapport with a patient.

This is the patient's story of the presenting problem and any additional details that led the patient to visit the psychiatrist. This includes information regarding why the patient is seeking help at a particular time (the "why now" aspect of the patient's life). This usually involves a triggering event or something that caused the patient to choose this point in life to seek help.

Realize there is no one particular way to take the history of present illness. Each person may differ in obtaining this important part of the examination. Remember different approaches may be needed depending on the circumstances (eg, emergency department consult versus a forensic evaluation).


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