What is the focus of past medical history during a history and Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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List medical problems, both past and present, and all medical illnesses. At least ask a few screening questions regarding medical illnesses (such as whether a patient sees a primary care physician regularly or at all). If possible, try to obtain the patient's entire medical records rather than depending solely on the patient's self-report; frequently, collateral information will be essential in determining psychiatric diagnoses. Even the most minute detail of a patient's medical history, from as far back as childhood, could play a significant role in the presenting problem. Be certain to inquire about specific events that may have occurred in childhood, such as falls, head trauma, seizures, and injuries with loss of consciousness. All of these could be relevant to their current problems.

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