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NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES DEPARTMENT OF PSYCHIATRY

SCHEME FOR CASE TAKING

1. 2. 3. 4. 5. 6.

History Mental Status examination Physical examination Summary Formulation Investigations, treatment & follow-up

The components of case taking are described in the following pages; the material presented here is intended to enable students to follow a uniform method of case taking. HISTORY TAKING Name:

Sex:

Age: Socio-economic status:

Address:

Informants (Mention here the source of information, relationship of the informant with the patient and length of acquaintance with patient and reliability of the information. It is often necessary to obtain information from more than one source. In certain types of illness like psychoses, relatives will be able to provide more reliable information while in neurotic illnesses, the patient would be the best informant. When information is collected from more than one source, do not collage the accounts of several informants into one, but record them separately) Complaints and their duration (Record the complaints in a chronological order. Do not write a long list of complaints, but present the salient disturbances in the different areas of functioning. While some patients / relatives may present an elaborate a list of their complaints, others might not spontaneously report their difficulties unless more direct questions are posed. Hence, use your skills and discretion in eliciting the complaints.) History of present illness: Give a detailed and coherent account of the symptoms from the onset to the time of consultations including their chronological evolutions and course. Specific attention must be paid to the following:

Onset: Note if the onset of the symptoms is abrupt (onset in 48 hrs), acute (i.e., developing within few hours – 2 weeks, insidious (few weeks to few months).

Precipitating factors: Enquire about any precipitating events. These could be physical (febrile illness) or psychological in nature (e.g death/loss). Ascertain whether the events closely preceded the illness or were consequences of the illness ( e.g loss following the outset of a schizophrenic illness).

Course of the illness: The course of an illness can be episodic (discrete symptomatic periods with intervening period of normalcy, continuous or fluctuating (Periodic exacerbations in a continuous illness). Also a different pattern of symptoms may evolve in a continuous illness. For example illness, while in the later stages apathy and emotional blunting might be prominent. Graphic presentation of the course of illness can often be very informative, as shown below. Financial loss

2/12 Age 25 yrs Untreated

Got married

2/12 Age: 27 yrs No definite precipitating factor. Treated with antidepressants.

2/12 Present episode Age: 30 yrs

Associated disturbances: Enquiry should also be made of impairment in other areas of functioning these include disturbances in sleep, appetite, weight, sexual life. Social life and occupation, the specific nature of the disturbance and the degree of disability should be recorded. Lastly, certain historical details must be routinely enquired into, to rule out an organic aetiology. These include: history of trauma, fever, headache, vomiting, confusion, disorientation, memory disturbance, history of physical illness like hypertension/diabetes and history of substance abuse, while these details are important regardless of the nature of presentation, they are particularly important in the elderly. Family History Draw a three generation genogram with standard symbols (Some of them are depicted below)

Affected male, female

Unaffected male, female

Consanguineous union

Index Patient

Abortion

Dead

Give a description of the individual family members (parents and siblings). The description should include information as to whether they are living or dead, age (or age of death), education, occupation, marital status, personality and relationship with the patient. Describe the socioeconomic condition of the family, leadership pattern, role functions and communication with the family. Enquire about the physical and/or psychiatric illnesses in the family and record in detail.

Personal History 1. Birth and early development Record the details of prenatal, natal and post natal periods, was the birth at full term? Whether delivered in hospital or at home? Any complications during delivery? Any Physical illnesses in the post natal period? Ascertain whether milestones of development were normal or delayed. 2. Behaviour during childhood Enquire about sleep disturbances, thumb-sucking, nail-biting, temper tantrums, bedwetting, stammering, tics, and mannerisms. Look for conduct disturbances in the form of frequent fights, truancy, stealing, lying and gang activities. Also enquire about relationship with parents, siblings and peers. 3.

Physical illnesses during childhood Record physical illnesses suffered in childhood. Enquire specifically regarding epilepsy, meningitis and encephalitis.

4. Schooling: Enquire about age of beginning and finishing school, type of school attended, scholastic performance, attitudes towards peers and teachers. 5. Occupation Age of starting work; jobs held, in chronological order; work satisfaction, competence, future ambitions. 6. Menstrual history Enquiry about age of menarche; reaction to menarche, regularity of periods; dysmenorrhea, menorrhagia/oligo menorrhea; emotional disturbances in relation to menstrual cycle.

7. Sexual history Enquire about age at onset of puberty; level of knowledge regarding sex and mode of gaining the same, masturbatory practices; anxiety related to sexual fantasies/practices, Homosexual and heterosexual orientation, fantasies and experiences, extramarital relationships.

8. Marital history Enquiry regarding age at time of marriage, whether arranged by elders of by self, was there mutual consent of the partners; age, education occupation health and personality of partner, quality of marital relationship, any separation or divorce. Note the number of children, their ages and health status. 9. Substance use Use and abuse of alcohol, tobacco and drugs; Enquire about smoking and drinking pattern and abuse of other drug like cannabis, opiates etc.

Premorbid Personality In this description of the personality prior to the beginning of the mental illness, do not be satisfied with a series of adjectives and epithets, but give illustrative anecdotes and detailed statements. Aim at a picture of an individual, not a type; the following is merely a collection of hints, not a scheme. It will not be possible to cover all the items listed in the course of the first interview, but an attempt should be made, particularly in cases of neurosis or affective disorder, to elicit evidence about all aspect of pre-morbid personality in the course of explorations extending over a period. 1.

he family (attachment, dependence); to friends, groups, societies, clubs; to work and workmates (leader or follower, organizer, aggressive, submissive, ambitions, adjustable, independent). 2. es: Hobbies and interest books, plays, pictures, preferred, memory, observation, judgment, critical faculty. 3. Bright and cheerful or despondent, worrying or placid; strung or calm and relaxed; optimistic or pessimistic; self-depreciative or satisfied; mood stable or unstable with or without any occasion. 4. a. ty: welcomes or is worried by responsibility, makes decisions easily or with difficulty; haphazard and slapdash or methodical and meticulous; rigid or flexible; cautious, fore-sightful and given to checking or impulsive and slipshod; persevering and determined or easily bored or discouraged. b. Self – confident or shy and timid, insensitive or touchy and sensitive to criticism, trusting or suspicious and jealous, emotionally-controlled or quick-tempered and irritable, tactful or outspoken; enjoys or shuns self-display; quiet and restrained or expressive and demonstrative in speech and gesture, interest and enthusiasms sustained or evanescent, tolerant or intolerant of others; adaptable or rigid. 5. nergetic or sluggish, output sustained or fitful, fatigability, any regular or irregular fluctuations in energy or output. 6. Frequency and content of daydreaming. 7. Eating (fads); alcohol consumption; self-medication with drugs or other medicines specify amounts taken recently and earlier tobacco consumption; sleeping; excretory functions.

MENTAL STATUS EXAMINATION (MSE): A systematically conducted mental status examination is an important component of case taking it is essential to record the observations properly, whenever positive findings are obtained, they should be described in detail. It is not adequate to say `delusions present’ or `hallucinations’. MSE has to be repeated several times during the course of the illness to know the evolution of symptoms, effectiveness of treatment etc. The time frame covered by the MSE is restricted to the hour of observation, but extends longer, while the following account highlights the major components of MSE, details should be obtained from other sources cited. 1. GENERAL BEHAVIOUR: Description as complete, accurate, life like as possible, of the observations of ward staff and your own; the following points may be considered, though not exclusively. Enquiry about the ways of spending the day, eating, sleeping, cleanliness in general, self care, hair and dress. Behaviour towards other patients, doctors and nursing staff does the patient look ill? Note whether the patient is fully conscious, stuporose or comatose; is he in touch with surroundings? Is the patient relaxed or tense and restless / is he slow or hesitant? How does he respond to various requirements and situations? Are there abnormal responses to external events? Can his attention be held or diverted? Is the patient Co-operative? Can adequate rapport be established? Does the patient maintain adequate eye contact? Does the patient’s behaviour suggest that he is oriented/disoriented. Note the presence of any tics on mannerisms. Note the presence of any catatonic phenomena. 2. PSYCHOMOTOR ACTIVITY: Note if the Psychomotor activity is increased, decreased or normal. 3. SPEECH: Note here the form of utterances rather than the content does the patient speak spontaneously or only in response to questions? Is the amount of speech little or excessive? Is it high toned or low toned ? Is the tempo fast or slow? Is the reaction time increased or decreased? Is it relevant? Is the coherent? Describe under these headings; relevance, coherence, volume, tone, tempo, reaction time 4. THOUGHT:

Examine thought processes with respect toForm: Presence of formal thought disorder Stream: Flight of ideas, retardation of thinking, circumstantially, perseveration, thought blocking Possessions: Obsessions and compulsions, thought alienation. With respect to obsession, elicit their nature-ideas, doubts, imagery, impulses and phobias. Similarly clarify the nature of compulsive acts checking, counting or washing; Are these `controlling’ compulsions or yielding compulsions?

Content: Look for the presence of overvalued ideas and delusions before making an inference, a detailed description of the phenomenon must be given. Note whether the delusion is single or there are multiple delusions, the type of delusion (grandiose, persecutory, nihilistic etc.), the exact content of the delusion, whether they are fleeting or fixed, whether they are well systematized or poorly systematized and whether they are mood congruent or not; Enquire about worries and preoccupations, hypochondriacal and somatic symptoms. Depressive ideation, ideas of worthlessness, guilt, hopelessness and suicidal ideas must be enquired and recorded.

5. MOOD: This should be assessed by both subjective report and objective evaluation; assessment should be both escription should be given regarding the following components; the ffect (happiness, sadness, anxiety etc.), the f emotional experience, the ffective responses, changes in emotion in relation to environmental factors), , (in relation to thought processes) and s (in relation to situations). Note ity (rapid and extreme changes in emotion). 6. PERCEPTION: Record the presence of illusions and hallucinations. Enquiry should be made into the following modalities, vision, hearing, smell, taste, pain and deep sensations vestibular sensations and sense of presence; record also the presence of special varieties of hallucinations like functional hallucinations, reflex hallucinations, extra-campine hallucinations, synesthesia and autoscopy. Detailed descriptions of the actual experience should be obtained, for example, with respect to auditory hallucination enquiry whether the hallucinations are verbal or non verbal, continuous or intermittent, single voice or multiple voices; familiar or unfamiliar voice; first person, second person or third person; pleasant or unpleasant, if unpleasant, whether commanding, abusive or threatening; response to hallucinations; whether mood congruent. Distinguish hallucinations from imagery and pseudo-hallucinations. Other perceptual disturbances, that must be enquired into include heightened perception, dulled perception, depersonalization/derealization experiences. 7. COGNITIVE FUNCTIONS: (Detailed section given later):

Insight: test the patient’s level of awareness of his illness; does he think that he is not ill at all (absence of insight)? Does he recognize the presence of illness but gives explanation in physical term (partial insight)? Does he fully realize the emotional nature of his illness and the cause of his symptoms (insight present)? SUMMARY The purpose of a summary is to provide concise description of all the important aspect of the case to enable others who are unfamiliar with the patient to grasp the essential features of the problem. The summary should be presented in the same format as described in the previous pages.

FORMULATION This is the student’s own assessment of the case rather than as restatement of the facts. Its length layout and emphasis will vary considerably from one patient to another. It should always include a discussion of the diagnosis, of the etiological factors which seem important, a plan of management and an estimate of the prognosis, regardless of the uncertainty or complexity of the case, a provisional diagnosis should always be specified using the ICD. A complete physical examination is mandatory for each patient. INVESTIGATION, TREATMENT AND FOLLOW-UP Biochemical, radiological or psychometric investigations should be carried be out wherever appropriate all aspects of management viz physical, psychological and social interventions should be included in the treatment package though the relative emphasis may differ from case to case. Progress notes should be systematically recorded. CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS Clinical assessment includes the areas of 1. 2. 3. 4. 5.

Orientation Attention and concentration Memory Intelligence Judgment

ORIENTATION Three aspects are described to time, place and person the following questions may be asked in the relevant areas:

Time: 1. Approximately what time of the day is it? (If the patient is unable to reply a more specific question may be asked) 2. Is it morning, afternoon, evening or night? (In addition further questioning may be done to assess estimation of time) 3. Approximately how long is it since you had your breakfast/lunch tea/dinner? (OR) Approximately how long have I been talking to you? 4. What is the day today? (day of week) 5. What is the date (day of the month, month, and year) today? Place: 1. What place is this? (If the answer is not forthcoming, a specific question is asked) 2. Is this a school, office, hospital, restaurant etc.,? (If the patient says it is a hospital details may be asked depending on background) Person: a) Orientation to self is tested by asking the identity of the patient. b) Inquiring about the identity of the patient’s relatives or family members. ATTENTION AND CONCENTRATION: Tests used in clinical situation include 1. The digit span test 2. Serial subtraction 3. Days or months forward to backward 1. Digit Span Test a) Forward: Patient is given the following instruction: I will be saying some digits, listen to me carefully, When I finish saying them you will have to repeat them in the same order the examiner after instructing the patient. a) Give an example (for example if I say 3, 7 you repeat 3, 7) b) Read digits at the rate of one per second to the patient c) Notes whether the immediate response of the patient is correct or incorrect. The following digits may be used: 5-7-3 4-1-7 5-3-8-7 6-1-5-8 1-6-4-9-5 2-9-7-6-3 3-4-1-7-9-6 6-1-5-8-3-9 7-2-5-9-4-8-3 4-7-1-5-3-8-6 4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4 The digit span is the highest number of digits repeated correctly

The same digits of digits on one trial, a if the response is correct.

the same number of digits is given and credit is given

b) Backward The patient is instructed as follows: I will be saying some digits, listen to me carefully and procedure is the same as for digits forward. - The same digits be repeated not be used as for the forward test - Digit backward score is the highest number of digits correctly repeated backward after a

SERIAL SUBTRACTIONS: Increasingly difficult tests are presented. The examiner a) instructs the patient, b) gives an example of how to perform task, c) notes the responses verbatim and d) notes the time taken in seconds. Task: Correct response and the limit 0 to 0 reversed 40, 37, 34, 31 etc. in s. 100, 93, 86, 79 etc. Days or months may be asked for in backward to the patient who is familiar with the correct order. MEMORY: Assessment includes immediate, recent and remote memory a) Immediate memory – tested by digit span test b) Recent memory: Tested by: 1) Address Test. An address consisting of about 4-5 facts that is not known to the patient is slowly read to the patient after instructing him to attend to the examiner. He is engaged in conversation (to avoid rehearsal) and the response is noted verbatim. Recall is asked for after 3-5 minutes. 2) Asking the patient to recall events in the last 24 hours e.g., details of the time and amount in a meal, visitors to the hospital from an inpatient. Responses given by the patient should be noted of any cross-checked from reliable source. c) Remote memory: Information on life events i) date of birth or age ii) number of children iii) names and number of family members iv) time since marriage of death or any family member v) Year of completing education 4-5 facts may be asked that are relevant to the patients background and answers should be cross checked.

INTELLIGNECE This includes the areas of general information, comprehension, arithmetic and vocabulary. General information: information relevant to the patients literacy age or occupation may be asked e.g. in literatea) Name of Prime Minister b) 5 river, cities or states c) Capitals of countries d) Current events (major) For illiterates: a) Seasons b) Crops of fruits growing particular seasons c) Prices of food grains or food items d) Prices of land Comprehension: The ability to understand questions asked during an interview is an index. Specifically the following questions of increasing difficulty may be asked. 1. What will you do when you feel cold? 2. What will you do if it rains when you start to work? 3. What will you do when you miss the bus when you are on a journey? 4. What will you do when you find on your way that it will be late by the time you reach your work spot? 5. Why should we be away from bad company? Arithmetic: The following questions may be asked with increasing time units 1. How such is 4 rupees and 5 Rupees? 2. I borrowed 6 rupees from a friend and returned 2 rupees, how much do I still owe to him? 3. If a man buys cloth for 12 rupees and gives...