duration)
(WIth
COMPLAINTS ILLNESS
PRESENT
OF
HISTORY
interpersonal/ onset sleep
onset
others at routines
:remissions with or
POSSIBLE
PRECIPITATING
Bereavement,
Financial
loss,Physical onset to work.
socioeconomic associated prior interests,
about
with changes
:
ANY Failures, and
associated situation
etc.
work IN: feeling
CHANGES
CONTINUOUSEXcacerbation Developrment hatbits,
IF Personality patterns,
EPISODE
ONSET COURSE
FACTOR, Quarrels, / illness
of
Events medical eating
(4)
SOCIAL FUNCTIONING
- Dressing &Self Care
-Working at job / home
Relations with family members /
neighbours MEDICAL
PSYCHIATRIC I
(4) PAST
HISTORY
Current Medical Problems
- Past Medical History
-Symptoms pertaining to CNS
dystunction
Drug history
Systems review FAMILY HISTORY
-Psychosomatic disorders
-Details of psychiatric illness in past
-Type of family
Joint / Nuclear / Living alone
Nuclear extended/ other
- InterpersonalRelation
Home atmosphere and Influence
Consanguinity
-Birth Order
-Farnily Size
mental
-Family history of medical /
illness
(5)
1. PRENATAL HISTORY PAST PERSONAL HISTORY
nature of pregnancy; Length of
pregnancy; wanted/unwanted
- Birth traumas
2. EARLY CHILDHOOD
(through age 3)
(a) Feeding habits
Breast/bottle feed
Eating problems
(b) Early develop mental:
Walking talking. teething:
language development, motor
development signs of unmet needs,
sleep patterns strangers anxiety;
maternal deprivation, separation anxiety
etc.
(c) Toilet Training :
age, attitude of parents.
(d) Symptoms of behavior problems:
thumb sucking, temper tantrums ties,
head banging, rocking, night terrors,
fears, bed wetting, bed soiling, nail biting
etc.
(e) Personality as child:
Shy/Restiess /Withdrawn /Over active /
timid / Pattern of play
3. MIDDLE CHILDHOOD
(3 to 11)
Early school history - Phobias, peer
relations cruelty to animals, adjustments
etc.
4. LATER CHILDHOOD
(Puberty through adolescence)
Social Relationship
School History
Congnitive & Motor development
adolescent emotional or physical
problems
(6)
5. PSYCHOSEXUAL HISTORY
(Childhood through adolescent)
Acquisition of knowledge attitude of
Parents, attitude towards sex etc.
Mentural History
6. RELIGIOUS BACKGROUND
7. ADULTHOOD
Occupational Choice, ambitions,
relations with authority, colleagues &
subordinates, conflicts etc.
Social Activity -friends, family &society
Adult Sexuality
Sexual relationship
() Marital history-age, adjustment,
management, attitudes CURRENT SOCIAL SITUATION
PREMORBID PERSONALITY
Residence, crowding, privacy income,
public assistance, social network etc.
1. Social relations to family, friends, work
mates
2. IntellectualActivities and interests
3. Mood
4. Character
5. Standards
6. Energy Initiative
7. Fantasy life
PHYSICAL EXAMINATION
8. Habits
(7)
GENERAL DESCRIPTION MENTAL STATE EXAMINATION
APPEARANCE
Body type, posture, clothes,
frightened, apathetic, perplexed, grooming.
anxiety,restless, eye contact. signs of
BEHAVIOURAND PMA
Gait, ties, twiches, stereo
rigid, hyperactive, agitation,types, echopraxia,
waxy. gestures,
mannerism
SPEECH&LANGUAGE
Slow, Pressured, monotonous,loud, slurred,
stuttering. echolalia, intensity, pitch,
spontaneity, productivity, manner, reaction
time, voccabulary
LANGUAGE
Coherence, comprehensibility, clang
association, neologism etc.
MOOD &AFFECT DELETE
(1) MOOD
How does feel, depth, intensity, duration,
fiuctuation, depressed, iritable, anxious,
angry, expansive, euphoric, awed, futie
(2) AFFECTIVE EXPRESSION
broad, restricted, depressed, blunt or flat,
shallow, anhedonic, labile, range of
expressions
APPROPRIATENESS
Appropriateness to thought content culture &
examination setting.
PERCEPTUAL DISTURBANCES
HALLUCINATIONS&ILLUSIONS
Auditory /visual etc. , content circumstances
of occurrances;
8
DEPERSONALIZATION &DEREALIZATION
THOUGHT PROCESS STREAM
A. Disorders of tempo:
- Flight of ideas-prolixity
- Inhibition of Retardation of thnking
Circumstantiality
B. Constinuity
Perseveration
Thought block
POSSESSION OF THOUGHT
1. Obsessions &compulsions
2 Thought alienation
CONTENTS OF THINKING
Delusions, Content, its organization,
somatiC, congruence, bizzareness,
persecutory, jealousy, love, grandiose, ill
health,guilt, nihilistic etc.
FORM OF THINKING
Formal thought disorder, loosening
Consistancy, organization continuity
PREOCCUPATIONS
About illness, environment,
recurrent,
hypochondriacal, suicidal ideations ideas,
IDEAS
Reference, influence
(9)
SENSORIUM &COGONITION
1. CONSCIOUSNESs
Clear, clouding, somnolence, stupor,
coma, alert,fugue
2. ORIENTATION
Time
Place
Person
3. ATTENTION &CONCENTRATION
4. MEMORY
Impariment, denial, confabulation,
castastrophicreaction
(a) Immediate
(b) Recent
(c) Recent Past
(d) Remote
5. INTELLIGENCE
Education, counting, calculation,
GK, IQ
6. ABSTRACTION
7. CALCULATION
8. JUDGEMENT
Social
On Test
9. INSIGHT
Present/absent/ partial
SUMMARY
(10 )
PROVISIONAL DIAGNOSIS
FINAL DIAGNOSIS
SIGNATURE RESIDENT
sIGNATURE CONSULTANT
OPINION
Case Summary &Dlscharge Record
INDOOR NO
SEX
Age
WARD NO
Complaints
Family History
Personal History
History of Present illness
Prysical Findings
Wental Status Exam.
irvestigations
Treatmet
Course in hospítal
(DOA-DOD)
Final Diagnosig
Condition at discharge
Recommendation
