Wednesday, June 01, 2016

PSYCHIATRY CASE TAKING - PROFORMA

            Case – taking in psychiatry is both a science and an Art. In so far as the case is systematically worked up as in most relevant information in as short a time as possible and to synthesize this information to arrive at a diagnosis and work out a management plan is an art, which would be mastered over time. As in traditional medicine, perhaps to a greater extent, almost importance should be given to the elicitation of history.  This should be supplemented by a systematically carried out mental status examination and physical examination.  The following is the scheme for case taking.
(1)               History
(2)               Mental Status Examination
(3)               Physical Examination
(4)               Summary
(5)               Initial formulation
(6)               Investigations, treatment and follow up
(7)               Final formulation
            These components of case taking are described in the following pages.  The material presented here is intended to enable residents to follow a uniform method of case taking.  It has not been possible to deal with all the areas exhaustively.  Residents and students are instructed to read texts cited in the end to become more proficient in case taking.
HISTORY TAKING
Name:                                                  Age:                                                    Sex:
Education:                                                       Occupation                  Marital Status:
Socioeconomic status:                                                                         Place:
Informant:
            Here mention the source of information, relationship of the informant with the patient, intimacy 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 illnesses like psychoses, relatives will be able to provide more reliable information while in neurotic illnesses; patient would be the best informant.  When information is collected from more than one source do not coalace the account 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 my present an elaborate 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 consultation including their chronological evolution and progression.  Specific attention must be paid to the following.
(a)             Onset:  Note if the onset of the symptoms is acute (i.e. developing within few hours) sub acute (few days to few weeks) or gradual (few weeks to few months)
(b)            Precipitating factors:  Enquire about any precipitating events, these could be physical (eg. A febrile illness) or psychological in of less. Ascertain whether the events, preceded the illness or wore consequences of the illness i.e, job loss following the on of a schizophrenic illness.
(c)             Course of the illness:  The course of as illness can be episodic (discrete symptomatic periods with intervening periods of normalcy), (continuous of fluctuating) (periodic exacerbations of a continuous illness).  Also a different pattern of symptoms may evolve in a continuous /illness.  For example delusions, hallucinations, and intense affects may be prominent in the initial phases of a schizophrenic 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                                                                         Got married
Excitement / suspiciousness
Talking to self / laughing to self / crying spells suicides ideas/ideas of helplessness, hope ensues, worthlessness presentory ideas /    / ideas of references, Hearing voices / Anxiety symptoms.
(d)            Associated disturbances:  Enquiry should also be made of impairment in other areas of functioning.  These include disturbances in sleep, appetite, weight, sexual life, special life and occupation.  The specific nature of the disturbances and the degree of disability should be recorded.
Lastly, certain historical details must be routinely enquired into rule out an organic, etiology.  These include history of trauma, fever, headache, vomiting, confusion disorientation memory disturbance, history of physical illnesses 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.
        Enquire about both past physical, illnesses and past psychiatric illnesses:  Try to ascertain the nature and duration of symptoms, the nature of treatment received, and the pattern of response.  In certain instances, it may be more meaningful to describe the previous episodes in the history of present illness rather than in the past history (for example frequent ….
FAMILY HISTORY:
        A family tree should be drawn with conventional tools as shown below:
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 or death) education, occupation & marital status, personality and relationship with the patient, enquire about the physically and / psychiatric illnesses in the family and record it in detail.  Describe the socioeconomic condition of the family, leadership pattern, role functions and communication within the family.
PERSONAL HISTORY:
v    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 periods.  Ascertain whether milestones of development were normal or delayed.
v    Behavior during childhood.  Enquire about sleep disturbances thumbs, 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, sibling and peers).
v    Physical illness during childhood:  Record physical illness suffered in childhood.  Enquire specifically regarding epilepsy meningitis and encephalitis.
v    School:  Enquire about age of beginning and finishing school, type of school attended; scholastic performance, attitudes towards peers and teachers.
v    Occupation:  Age of starting work, jobs held in chronological order, work satisfaction, competence, future ambitions.
v    Menstrual history:  Enquire about age of menarche; reaction to menarche; regularity of periods; dysmenorrhoea; menorrhagia/ menstrual cycle.
v    Sexual history:  Enquire about age at onset of puberty; level of knowledge regarding sex and mode of finding the same masturbatory practices, anxiety related to sexual fantasies/practice Homosexual and heterosexual fantasies, inclinations and experiences, extramarital relationships.
v    Marital History:   Enquire regarding age and time of marriage/whether arranged by elders or by self was there mutual consent of the partners/age, education, occupation, health and personality of partner, quality of mental relationship, and separation or divorce.  Note the humbar of children, their ages and health status.
                 Use and abuse of alcohol, tobacco and drugs:  Enquire about smoking and drinking pattern and abuse of other drugs like cannabis, opiates, barbiturates etc.
PREMORBID PERSONALITY:   Personality of a patient consists of those habitual attitudes and patterns of behavior which characterize an individual.  Personality sometimes changes after the onset of an illness.  Get a description of the personality before the onset of the illness.  Aim is to build up a picture of individual, not a type.  Enquire with respect to the following areas.
1.               Attitudes to others in social family and sexual relationship:  Ability to trust others, and make and sustain relationships, )anxious or secure) (leader or follower, participation, (responsibility) capacity to make decisions, dominant or submissive, friendly or emotionally cold, evidence of any jealousy, suspicion, guardedness etc.  Evidence of difficulty in role taking gender, sexual familial, parental and work.
2.               Attitudes to self:  Egocentric, selfish, indulgent, dramatizing, critical, deprecatory, over concerned self consists satisfaction or dissatisfaction with work. Attitudes toward health and bodily functions.  Attitudes to past achievements and failures and to the future.
3.               Moral and religious attitudes and standards:  Evidence of rigidity of compliance permissiveness or over consciousness, conformity or rebellion.  Enquire specifically about religiour beliefs.
4.               Mood:  Enquired about:  (stability of mood) (mood swings) whether (anxious, irritable warrying) or these, whether (lively) or (gloomy). Ability to express and control feelings of anger, anxiety, or depression.
5.               Leisure activities and interests:  Interest in reading, play, music, movies, etc.  Enquire about creative ability.  Whether leisure time is spent alone of with friends.  Is the circle of friends large or small.
6.               Fantasy Life:  Enquire about (content of day dreams and dreams.  Amount of time spent in day dreaming.
7.               Reaction pattern to stress:  (Ability to tolerate frustrations, losses, disappointments, and circumstances arousing anger, anxiety or depression.  Evidence for the execessive use of particular defense mechanisms such as denial, rationalization, projection etc.
8.               Habital:  Eating, sleeping and 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 ‘hallucination ++’ M.S.E. has to be repeated several times during the course of the illness to know the evolution of symptoms, effective of treatment etc.  the time frame covered by the MSE is not restricted to the hour of observation, but extends longer.  While the following account highlights the major components of MSE, details should be obtained form other sources cited.
(1)   GENRAL BEHAVIOUR & APPEARANCE
            Description as complete, accurate, life like as possi  of the observations of ward staff and your own.  The following points may be considered, though not exclusively.
            Enquire about the way of spending the day, eating, sleeping, cleanliness in general self care, hair and dress, behavior towards other patients, doctor and nursing staff.  Doss the patient look ill?  Note whether the patient in full conscious, stuporess or comatose.  Is he in touch with surroundings?  Is the patient relaxed or tense and restly.  Is he slow or hesitate.  How has he respond to various external events, can his attention be held or diverted?  Patient co-operative?  Can adequate rapport established?  The presence of any ties or mannerism.  Note the presence any catatonic phenomena.
(2)   PSYCHOMOTOR ACTIVITY:
     Note if the psychomotor activity is increased decrease or normal.
(3)   TALK
            Note here the form of utterances rather than the content.  Does the patient speak spontaneously of only in response to suggestions.  Is the amount of speech little excessive is high toned or law toned.  Is the tumpo fast or slow.  Is the reaction time increased or decreased.  The prosody of speech maintained?  Is it relevant?  Is it coherent?

(4)   THOUGHT
(a)             Stream:  Flight of ideas, retardation of thinking circumstantiality, perseveration, thought blocking.
(b)            Form:  Presence of formal thought disorder.
(c)             Possession:  Obsessions and compulsions, thought alienation with respect to obsessions, elicit their nature ideas, dobbts, imagery, impulses and phobias.  Similarly clarify the nature of compulsive acts checking, counting or washing, are these controlling ‘compulsions or ‘Yinclding’ compulsions.
(d)            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 delusions is single or these are multiple delusions, the type of delusion grandiose, persecutory, nihilistic etc the exact content of the delusions, whether they are fleeting or fixed whether they are well systematized of poorly systematized and whether they are mood congruent or not.  Enquire about worries and preoccupations, hypochondriacally and somatic symptoms, Depressive ideation, ideas of a  X  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 X   (mood and prossertional (affect).  Description should be given regarding the following components:  the quality of emotion (happiness, sadness, anxiety etc), the intensity or depth of emotional experience, the range of affective responses, mobility reactivity (changes in emotion in relation to environmental factors), diurnal variation, congruity in relation to though processes) and appropriatness (in relation to situations).  Not any evidence of liability (rapid and extreme changes in emotion).
(6)   PERCEPTION:
            Record the presence of illusions and hallucinations, visions, hearing, smell touch, taste, pain and deep sensations, vestibular sensations and sense of presence.  Record also the presence of special variety of hallucinations like functional hallucinations, reflex hallucinations, extra campine hallucinations, cenaesthipathic hallucinations, synaesthesia and autoscopy.  Detailed descriptions of the actual experience should be obtained.  For example with respect to auditory hallucinations enquire whether the hallucinations are (verbal or non verbal):  continuous or intermittent:  single voice or multiple voices:  familiar various or unfamiliar, first person, second person or third person; pleasant or unpleasant if unpleasant whether commanding; abusive or threatening relationship of hallucinations to time of the day, and daily, activities; reaction to the hallucinations.  Are they mood congruent.  Distinguish hallucinations from imagery and proud hallucinations.
            Other perceptual disturbances that must be enquired into include heightened perception illed perception, depersonalization derealization experiences and disturbances in the perception time.

(7)   CONGNITIVE FUNCTIONS:
I.                   Attention and concentration:  Test for the ability to arouse and sustain attention.  Is there any distractibility?  Concentration can be tested by asking the subject to tell the days or months in reverse order or substration of serial sevens from 100. (Note answer and time taken).  It could also be tested by giving the patient four to seven digits to repeat forwards and backward.
II.                ORIENTATION:    Record the patients answers to questions about his own name and identity, the place where he is, the time of day and the date.
III.             MEMORY:  Test immediate, recent and remote memory.  The digit repetition test is a test of immediate memory.  To test recent memory, enquire about what patient had our breakfast the events of the day and what he ate the previous night.  Patients recall can be casted by presenting him an address and asking him to recall the same personal and impersonal events.  Always attempt to verify from the informant.
IV.             GENERAL INFORMATION:  The tests should be varied according some common questions include.
-          Name of the Prime Minister
-          Major cities of India
-          Name of the state, capital Chief Minister
-          Names of a foreign countries
V.                   INTELLIGENCE:   Patients, intelligence should be gauged from his educational level, occupational record, his general knowledge and supplemented by clinical tests appropriate to the background of the subject.  More standardized tests may be used if felt necessary.
VI.             ABSTRACT:   Patient can be asked to explain the meaning of certain used proverbs.  Similarly patient can asked to mention the similarities between certain objects a desk and a chair.
VII.          JUDGEMENT:   Assess (a) Personal judgment:  What is the patients attitude to the present event does he regard it as an illness?  Does he think treatment necessary.
(b)   Test Judgment:  Does the patient show appropriate behavior in social situation?  Is there any disinhibition.
(c)   Test Judgment:  What would the patient do if a stamped sealed addressed envelope is found in the street?  What would he do if the theatre in which he is watching a movie caught fire?
VIII.        INSIGHT:  Test the patients 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 terms (Partial insight)?  Does he fully realize the emotional nature of his illness and the cause of his symptoms (insight present)?
Staging of Insight
1.               Complete denial of illness.
2.               Slight awareness of being sick need help but, denying it at the same time.
3.               Awareness of being sick, but timing it on an ext. factors or organic factors
4.               Awareness that illness is due to something unknown in patient.
5.               Intellectual insight – admission that patient is it and that symptoms failure in social adjustment are due to patient own particular emotional feelings/disturbances without apply that knowledge to failure experiences.
6.               True emotional insight – emotional awareness of the movies and feelings within the patient and the important people in his / her life, which can lead to basic changes in behaviour.
PHYSICAL EXAMINATION
                 A detailed physical examination is must in all cases.  When the patient is excited or uncooperative at the time of initial presentation, carry out physical examination to the extent permissible, after sedation is necessary.  This should always be followed by a detailed examination at the earliest time that patient is co-operative.  Pay particular attention to neurological examination.
SUMMARY
                 The purpose of a summary is to provide concise description of all the important aspects, 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.
INITIAL FORMULATION
                 This is the resident’s own assessment of the case rather than a restatement of the facts.  Its length, layout and emphasis will very considerably from one patient to another.  It should always include a discussion of the diagnosis  logical factors which seem important, plan of management and an estimate of the prognosis.  Regardless of the uncertain or complexity of the case, a provisional diagnosis should all be specified using the ICD.

INVESTIGATIONS TRATMENT AND FOLLOW UP
                 Biochemical, radiological or psychometric investigation should be carried out wherever appropriate.  All aspects of management viz.  physical, psychological and serial interventions should be included in the treatment package though the relative emphasis may differ from case to case progress not should be systematically recorded.
FINAL FORMULATION
                 This is a revision of the initial formulation drawn up at the time of discharge.  It should specify any divers of opinion and should state the views of the consultant clearly.  It should be written in the light of the patient response to treatment and other information becoming avail since the time of admission.  Its length and layout will considerably but it should always include a final diagnose with amplifying comments and an estimates of the prognosis.
EXAMINATION OF NON-CO-OPERATIVE & STUPOROSE PATIENTS
(Kirby, 1921)
                 The difficulty of getting information from no-co-operative patients should not discourage the physician from making and recording certain observations.  These may be of great importance in the study of various types of cases and give valuable data for the interpretation of different clinical reactions.  It is hardly necessary to say that the time to study negativistic reactions is during the period of negativism, the time to study a stupor is during the stupors phase.  To wait for the clinical picture to change or for the patient to become more accessible is often to miss an opportunity and leave a serious gap in the clinical observation –obviously it is necessary in the examination of such cases to adopt some other plan than that used in making the usual ‘mental, status’.  The following guide was devised to cover in a systematic way the most important points for purposes of clinical differentiation.

I.                         GENERAL REACTION AND POSTURE:
(a)          Attitude voluntary or passive
(b)         Voluntary postures comfortable, natural, constrained or awkward.
(c)          What does the patient do if placed in awkward or uncomfortable positions.
(d)         Behavior towards physicians and nurses: resistive, evasive, irritable, apathetic, compliant.
(e)          Spontaneous acts: any occasional show of playfulness, mischievousness or assaultiveness.  Defense movements when interfered or when pricked with pin.  Eating and dressing.  Attention to bowels and bladder.  Do the movements show only initial retardation or are they consistent throughout?
(f)          To what extent does the attitude change?  Is the behavior constant or variable from day to day?  Do any special occurrences influence the condition? 
II.                      FACIAL EXPRESSION
      Alert, attentive, placid, vacant, stolid, sulky, scowling, averse, perplexed, distressed etc.  Any play of facial expression or expression or signs of emotion:  tears, smiles, flushing, perspiration.  On what occasions.
III.                   EYES
      Open or closed.  If closed, resist having lid raised.  Movements of eyes absent or obtained on request; give attention and follow the examiner or moving objects; or show only fixed gazing, furtive glances or evasion.  Rolling of eyeballs upwards.  Blinking, flickering, or tremor   Reaction to sudden approach of threat to stock pin in eye.  Sensory reaction of pupils (dilation from painful stimuli or irritation to skin of neck).
IV.                   REACTION TO WHAT IS SAID OR DONE
        Commands, show tongue, move limbs, grasp with hand (clinging, clutching etc).  Motions slow or sudden.  Reactions to pin-pricks.  Automatic obedience:  tell patient to protrude the tongue to have pin stuck into it.  Echopraxia:  imitation of actions of others.
V.                      MUSCULAR REACTIONS
      Test for rigidity:  muscles relaxed or tense when limbs or body is moved.  Catalepsy, waxy flexibility.  Negativism shown by movements in opposite direction of springy or cog wheel resistance.
Test head and neck by movements forward and backward and to side.
Test also jaw, shoulders, elbows, fingers and the lower extremities.
Does distraction or command influence the reactions?
Closing of mouth, protrusion of lips.
VI.                   EMOTIONAL RESPONSIVENESS
      Is feeling shown when talked to of family or children?   When sensitive points in history are mentioned or when visitors come?
Note whether or not acceleration of respiration or pulse occurs, also look for clushing, perspiration, tears in eyes, etc.  Do jokes elicit any response?
Effect of unexpected stimuli (clap hands, flash of electric light)
VII.                SPEECH
      Any apparent effort to talk, lip movements.  Whispers movements of head.  Note exact utterances with accompanying emotional reaction (may indicate hallucinations).
VIII.             WRITING
      Offer paper and pencil.  Irresponsive or partially stupors patients will often write when they fail to talk.





TYPED BY DR.VRAJESH , JUNIOR RESIDENT, PSYCHIATRY, CALICUT MEDICAL COLLEGE.


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