The medical history is the fundamental tool to guide the relevant medical and psychometric examinations in order to arrive at a correct diagnosis.
What is described in this post is simply a reminder guide on the most relevant aspects to consider when taking a medical history.
Below I outline the structure of the medical history I typically use. Depending on the initial information, we should guide the subsequent examination in order to clarify, in a standardized and objective manner, the various diagnostic hypotheses considered.
1. REASON FOR CONSULTATION
This section is for freely recording the reasons given by the parents or the adolescent regarding the problem for which they are seeking help. The following standard questions must be answered: What's wrong with him/her? Since when? And why do you think it's happening?
It consists of obtaining the information as objectively as possible, although they are allowed freedom (with few directives) to express both the problem and the explanations they find.
I recommend starting with the "reason for consultation" because it facilitates the creation of a trusting scenario, necessary to establish the best possible relationship with the patient.
- PERSONAL BACKGROUND
- Obstetric and perinatal history
First-time birth? Planned? Natural conception, artificial insemination, adopted? Bleeding during the first trimester? Threatened miscarriage?. ¿Was the delivery at term? Was it instrumental or surgical? Did the baby cry immediately? Is there information about the Apgar score? Did the baby require resuscitation? What was the presentation: cephalic or breech? Were any maneuvers necessary? Were there any malformations (e.g., hip dysplasia)?
Did the mother experience any medical problems during pregnancy: gestational diabetes, hypertension, anemia, infections…? Was intrauterine growth normal? Was fetal movement normal?
Did the infant require any type of neonatal pediatric care? Was there hyperbilirubinemia? Did the infant require phototherapy or any other intervention?
The important thing here is to detect the presence or absence of any fetal distress, as well as to assess fetal well-being during pregnancy.
- Development background
- Psychomotor: Explore: Neuromuscular tone, crawling, first steps with support, beginning of independent ambulation.
- Language: First words, first phrases. Language comprehension, production and pronunciation (speech disorders). Prosody, verbal stereotypies, echolalia.
- Sphincter control: Bladder control. Inquire about primary and/or secondary enuresis. Anal sphincter control: Investigate if there have been encopretic episodes and what type.
- Sleep: Difficulty falling asleep, waking up, nightmares, jactatio capitisSleepwalking, night terrors, sleep talking, sleep apnea. Does he/she sleep with his/her parents?
- Feeding: Was the baby breastfed, and for how long? Infant reaction to weaning and the introduction of solid foods. Loss of appetite (hyporexia), overeating, picky eating, food refusal, chewing difficulties. Intolerances, allergies.
- Emotional development: Interaction with the environment, exploratory behavior, fears, first smiles, separation anxiety, fear of strangers, transitional objects (e.g., teddy bears…), pacifier use (how long and reactions when giving it up?).
Attachment style. Attachment figures (father/mother). Temperament type.
- Social development: Approach behaviors, isolation, relationships, acceptance among peers, skills for relating to other children
- ScholarshipAdaptation, performance. Here, the reaction when starting daycare or preschool is important, especially episodes of separation anxiety and their duration.
- Medical history
Infections, vaccine reactions, food intolerances, allergies, febrile seizures (typical or atypical, and whether they required treatment). Any neurological or other illnesses? Surgical procedures. Hospitalizations and duration.
3. FAMILY BACKGROUND
Family genogram.
– Ask specifically about the existence of family history of psychiatric, neurological, neurodevelopmental conditions and any other medical circumstances that may be related to the reason for consultation.
– Type of family: Normal, single-parent, same-sex parent, separation/divorce, adoptive…
– Quality of coexistence (family disharmony, conflict, marginalization, as well as any other risk factor, e.g., unemployment, poverty, etc.).
SUPPLEMENTARY EXAMINATIONS
DOCTORS
With the information gathered above, we would be in a position to decide which additional tests would be indicated. The most common are:
– Basic neurological examination
– In cases of language development problems with impaired comprehension: Auditory Brainstem Responses, Electroencephalogram. Depending on the possible causes (organic diagnostic hypotheses), a Nuclear Magnetic Resonanceor, in cases of infection (e.g., toxoplasmosis), a Computed Tomography.
– In other neurodevelopmental problems, e.g., Autism Spectrum Disorders or others, it would be indicated to perform a array HCG.
- When the problem is of emotional or psychological origin, medical examinations are not usually performed, except in cases of significant anxiety or moderate/severe affective disorders in which an examination would be indicated. thyroid function .
Depending on the pharmacological treatment (if indicated), some additional tests are required, such as in the case of psychostimulants: electrocardiogram, heart rate, blood pressure, weight, and height. In the case of neuroleptics: liver function tests, weight, amylase levels, and extrapyramidal symptoms.
PSYCHOMETRIC
As in the previous section, we must decide which psychometric assessment instruments to use. Administering questionnaires and/or scales in an undesignated manner is not recommended, as it wastes time and suggests that the information collected was not done properly.
The purpose of psychometric assessment is twofold: Firstly, to more objectively determine the diagnosis and its severity. Secondly, to anticipate therapeutic planning, both psychotherapeutic and pharmacological.
The scales and tests to be performed should be standardized and adapted to the age and cognitive status of the patient.
Let's look at some examples.
– If it is a neurodevelopmental problem, we should use scales that specify the clinical presentation, as well as the assessment of cognitive abilities. There are scales for ASD, Mental Retardation, Specific Disorders. Also for cognitive assessment: McCarty, WPPI, WISC-IV, Developmental Scales …It is very important to objectively define language comprehension. I use the Dichotic Listening and the Token Testalthough there is a wide variety of instruments.
– If we suspect ADHD, it would be advisable to go Questionnaires for parents and teachers, Stroop, CPT, WISC-IV (depending on age), Tower of Hanoi, and the Wisconsin Test with the aim of also evaluating executive functions.
– If we suspect an emotional disorder and/or anxiety, we would evaluate it with some anxiety questionnaire (e.g. STAT, (for state and trait anxiety). I usually use the Multidimensional Anxiety Scale for ChildrenAlthough there is a wide variety. In cases where an affective disorder is suspected, I use Young Scale for Bipolar Disorder in Children and Adolescents, Beck Depression Inventory for Adolescents and / or long-term contract,
I believe the important thing is to pinpoint the diagnosis, as well as use this information to decide on the treatment modality.
DIAGNOSIS
In order to understand each other as professionals, as well as for any research task, to seriously anticipate the prognosis, and to carry out preventive and epidemiological activities, it is essential to make a diagnosis.
The classifications in use are:
- DSM-5 of the American Psychiatric Association
- ICD-11 of the World Health Organization.
I usually use DSM 5.
TREATMENT PLAN
We will decide whether to implement it psychotherapy, psychopharmacological treatment or both. We should indicate those that are greater scientific evidence they have in terms of results.
We will always value the benefit/risk of the interventions we decide on and, as far as possible, adhering to the corresponding clinical guidelines.
On this website you can find some of the scales I usually use at this link