NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES

DEPARTMENT OF PSYCHIATRY

SCHEME FOR CASE TAKING

1. History
2. Mental Status examination
3. Physical examination
4. Summary
5. Formulation
6. 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, sub-acute (few weeks) or 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 Got married

2/12 2/12 2/12

Age 25 yrs Age: 27 yrs Present episode
Untreated No definite precipitating Age: 30 yrs
factor.
Treated with antidepressants.

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 socio-
economic 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, bed-
wetting, 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. Social relations: The family (attachment, dependence); to friends, groups, societies, clubs;
to work and workmates (leader or follower, organizer, aggressive, submissive, ambitions,
adjustable, independent).
2. Intellectual activities: Hobbies and interest books, plays, pictures, preferred, memory,
observation, judgment, critical faculty.
3. Mood: 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. Character:
a. Attitude to Work and responsibility: 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. Interpersonal relationships: 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. Energy & Initiative: Energetic or sluggish, output sustained or fitful, fatigability, any regular
or irregular fluctuations in energy or output.
6. Fantasy life: Frequency and content of daydreaming.
7. Habits: 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 to-

Form: 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 longitudinal (mood) and cross-sectional (affect). Description should be given regarding the
following components; the quality of affect (happiness, sadness, anxiety etc.), the intensity or
depth of emotional experience, the range of affective responses, reactivity (changes in emotion in
relation to environmental factors), diurnal variation, congruity (in relation to thought processes)
and appropriateness (in relation to situations). Note any evidence of lability (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. Orientation
2. Attention and concentration
3. Memory
4. Intelligence
5. 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 should not be presented more than once if the patient cannot repeat a particular
number of digits on one trial, a 2nd trial with the same number of digits is given and credit is given
if the response is correct.

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 maximum of 2 trials.

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

20-1 20 to 0 reversed in 15 secs. 40-3
40, 37, 34, 31 etc. in 60 secs. 100-7
100, 93, 86, 79 etc. in 120 secs.

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 literate-
a) 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 a shopkeeper 20 rupees; how much change
would he get back?
4. How many pencils can you buy for 2 rupees if one pencil costs quarter of a rupee (on 25
paise)?
5. If 18 boys are divided into groups of 6, how many groups will there be?
Time limits: 1 to 3 15 secs 4 to 5 30
secs
Correct answers: 1)9, 2)4, 3)9, 4)8, 5)3

Abstraction:
Tested by a similarities, differences and proverbs
Similarities: The patient is given the following instructions.
I will be giving you some pair of words. You have to tell me in what way they are alike, what is
common between them, or what is the similarity between them.
Orange - Banana (fruits)
Dog - Lion (animals)
Eye - ear (sense organs)
North - west (directions)
Table - chair (items of furniture)
Correct responses, i.e., abstract responses are given in brackets
Differences being an easier task are always presented before similarities

Differences:
The instructions are as follows: I will be presenting to you some pairs of words listen carefully and
tell me in what they are different from each other.
Stone - Potato (not edible - edible/hard-soft)
Fly - Butterfly (small-large/not colourful-colourful)
Cinema - Radio (audio-visual-audio)
Iron - Silver (heavy-light-dull-bright)
Praise - Punishment (Positive-negative/pleasant-unpleasant)

Proverbs:
The patient is asked the following questions
a) Whether he knows what a proverb is
b) An example of a proverb and what is means
If it is clear that the patient has the concept of a proverb the following may be asked
1) Slow and steady wins the race
2) A barking dog never bites
3) As you sow, so shall you reap
4) All that glitters is not gold or all that is white is not milk
5) Where there is a will there is a way
6) Empty vessels make more noise
7) Every potter praises his pot
8) It is useless to cry over spilt milk
The response of patient is to be noted verbatim and judged to be correct/incorrect.

JUDGMENT

Is assessed in the following areas

1) Personal
2) Social
3) Test

Personal: Judgment is assessed by inquiries about the patient’s future plans

Social: Judgment is assessed by observing behavior in social situations
Test Judgment: The following 2 problems are presented to the patient in a manner in which he can
comprehend.
1. Fire problem: If the house in which you are catches fire, what is the first thing you will do?
(correct answer – try to put if off with water)
 2. Letter problem: If when you are walking on the roadside you see a stamped and sealed
envelope with an address on it which someone had dropped, what will you do? (correct
answer post it in a letter box, or give it to the post man)

EXAMINATION OF NON-CO-OPERATIVE OR STUPOROSE

PATIENTS: (Kirby, 1921)

The difficulty of getting information from non-Co-operative patients should not discourage the
physician from making and recording observations. These may be of great important 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 negative reaction is during the period of
negativism, the time of study a stupor is during the stuporose 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 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 of uncomfortable positions?
D. Behavior toward physicians and nurses, resistive, evasive, irritable, apathetic, complaint
E. Spontaneous acts: any occasional show to playfulness, mischievousness or assaultiveness;
Defence movements when interfered with 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?

II. FACIAL EXPRESSION: Alert, attentive, placid, vaunt, stolid, sulky, scowling, averse perplexed
distressed, etc. Any play of facial expression or signs or emotion tears, smiles, blushing,
perspiration. On what occasions?

III. EYES: Open or closed if close, resist having lid raised. Movement of eyes absent or obtained on
request: give attention and follow the examiner or moving objects or show only fixed gaxing,
furtive glances or evasion.
Rolling of eyeballs upward. Blinking, flickering, or tremors of lids. Reaction to sudden approach to
threat to stick 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, clinching, etc.,). Motions slow or sudden. Reaction to pin-pricks. Automatic obedience:
tell patient to protrude the tongue to have pin stuck into it.
V. MUSCULAR REACTIONS: Test for rigidity, muscles relaxed or tense when limbs or body is moved.
Catalepsy, Waxy flexibility, Negativism shown by movement in opposite direction on springy or
cog-wheel resistance.

Test head and neck by movement forward and backward and to side
Test also the jaw, shoulders, elbows, fingers and the lower extremities
Does distraction or command influence the reactions?
Closing of mouth, prolusion of lips (`Schnauzkrampf”)
Holding of saliva, drooling.

VI. EMOTIONAL RESPONSIVENESS: Is feeling shown when talked to of family or

children? Or when sensitive points in history are mentioned or when visitors come?
Note whether or not acceleration of respiration or pulse occurs also look for flushing, 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. Unresponsive or partially stuporose patients will often write
when they fail to talk.