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Case History and Mse

The case history document provides details about a patient's socio-demographic background, chief complaints, history of present illness, biological functioning, family history, personal history, premorbid personality, and mental status examination. Informants are also identified. The mental status examination assesses the patient's general appearance, psychomotor activity, speech, affect, thinking, perception, cognition, judgment, and insight. A provisional diagnosis is noted.

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ILIKA GUHA MAJUMDAR Department of Psychology NCR
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177 views7 pages

Case History and Mse

The case history document provides details about a patient's socio-demographic background, chief complaints, history of present illness, biological functioning, family history, personal history, premorbid personality, and mental status examination. Informants are also identified. The mental status examination assesses the patient's general appearance, psychomotor activity, speech, affect, thinking, perception, cognition, judgment, and insight. A provisional diagnosis is noted.

Uploaded by

ILIKA GUHA MAJUMDAR Department of Psychology NCR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE HISTORY

Socio-demographic Details:

a. Name

b. Age/ Sex

c. Registration No.

d. Educational Qualifications

e. Occupation

f. Socio-economic background- Rural/ urban/ sub-urban

g. Domicile- Lower/ Lower-middle/ middle/ higher

h. Family type- nuclear/ joint

i. Marital Status-

 Number of children

j. Religion

Informants

Informant 1 Informant 2

Name

Age/Sex

Relationship with patient

Reliability of Information

Chief Complaints:

1.
2.

3.

4.

5.

Onset- Abrupt Acute Insidious

Course- Progressing Remission Fluctuating Static

Duration

Episode

Precipitating Factor

History of Present Illness

Biological Functioning:

1. Sleep
2. Appetite
3. Energy Level

Negative History

Past History
Family History

1. Family of Origin and Family Dynamics

2. Attitude of Family Members towards Illness

3. Family History of Psychiatric Illness

Personal History

1. Ante-natal
2. Natal
3. Post natal
4. Infancy and Childhood
5. Adolescence
6. Educational
7. Occupational
8. Marital
9. Sexual
10. Menstrual (for females only)
11. Substance use

Premorbid Personality/ Temperament (in case of Children)

1. Social Relations

2. Intellectual Activities, Hobbies and Interests

3. Predominant Mood

4. Character

a. Attitude to Self

b. Attitude to Work and Responsibility


c. Interpersonal Relationships

d. Standards in Moral, Religious and Health Matters

e. Energy and Initiative

5. Fantasy Life

6. Habits

MENTAL STATUS EXAMINATION

General Appearance and Behavior

 Built
 Accompanied by
 Gait
 Behaviour during interview
 Dressing
 Grooming
 Eye contact
 Cooperativeness
 Rapport

Psychomotor Activity

Speech

 Rate
 Tone
 Volume

Affect

 Subjectively

 Objectively

o Predominant affect
o Intensity
o Range
o Appropriateness
o Stability

Thinking

 Flow (increased/decreased)
 Form
o Relevant
o Coherent
 Content

Perception

Cognition

 Consciousness
 Orientation
a. Time
i. Date
ii. Day
iii. Month
iv. Year
v. Season
vi. Time spent in hospital
b. Place
i. Present location
ii. Building
iii. City
iv. State
v. Country
c. Person
i. Name
ii. Informant’s Name
iii. Relationship with Informant
 Attention
o Digit forward
o Digit backward

 Concentration
o Days of the week-forward
o Days of the week –backward
o 20-1
o 40-3
o 100-7
 Memory
o Immediate Retention and Recall (names of 3 things)
o Delayed Recall
o Recent Memory
i. How did you come to the room/hospital?
ii. What did you eat for breakfast/ lunch/ dinner today/ yesterday?
iii. Who came to meet you at the hospital or at home yesterday?

o Remote Memory
i.Date of birth
ii.Marriage anniversary
iii.Address
iv.Number of children
v.Names of children
vi.Number of years of work/schooling
vii.Place of work/schooling
viii.Major event that happened 2 years ago

 Intelligence
i. General fund of knowledge
ii. Arithmetic
iii. Reading
iv. Writing
v. Comprehension
vi. Abstract thinking
o Proverb testing (3 proverbs)
o Similarities
o Differences

Judgment

 Personal
 Social
 Test

Insight

i. Grade I (complete denial of illness)


ii. Grade II (slight awareness of being sick but denying at the same time)
iii. Grade III (Awareness of being sick, but it is attributed to external or physical
factors)
iv. Grade IV (Intellectual Insight)
v. Grade V (True Emotional Insight)

Provisional Diagnosis

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