CASE TAKING

CASE TAKING..

 Both a science and an art.

 The ability to systematically work up a case
and obtain the most relevant information in as
short a time as possible, to synthesize this
information, to arrive at a diagnosis and
workout a management plan is a skill which
should be mastered over time.
 SHOULD BE UNIFORM.
CASE HISTORY TAKING..

 TRADITIONAL MEDICINE- HISTORY TAKING-

 FOCUS ON SYMPTOMS
 THEIR DEVELOPMENT OVER TIME
 FREQUENCY
 SEVERITY
 ANY OTHER SIGNS NOTED BY OTHERS
SCHEMATA FOR CASE TAKING

 1. History
 2. Mental Status Examination
 3. Physical examination*
 4. Summary
 5. Initial formulation
 6. Psychological Assessment
 7. Final formulation
 * To be conducted by a Medical Examiner only
Outline of Psychiatric History

 I. Identifying data
 II. Chief complaint
 III.History of present illness
 IV.Past illnesses
 A. Psychiatric
 B. Medical
 C. Alcohol and other substance history
 V. Family history
Outline of Psychiatric History

 VI.Personal history
 A. Prenatal and perinatal
 B. Early childhood (Birth through age 3)
 C. Middle childhood (ages 3 ,“11)
 D. Late childhood (puberty through adolescence)
 E. Adulthood
Outline of Psychiatric History

 1. Occupational history
 2. Marital and relationship history
 3. Educational history
 4. Religion
 5. Social activity
 6. Current living situation
 7. Legal history
 F. Sexual history
 G. Fantasies and dreams
 H. Values
CASE HISTORY TAKING
SOCIO –DEMOGRAPHIC DATA / IDENTIFYING DATA

1. NAME
2. AGE
3. SEX
4. EDUCATION
5. OCCUPATION
6. ORDINAL STATUS
7. MARITAL STATUS
8. RELIGION
9. RURAL /URBAN
10. SOCIO-ECONOMIC STATUS
11. WITH WHOME THE PERSON LIVES
12. INFORMANT
13. RELATION WITH THE PERSON
14. INFORMATION- RELIABILITY AND ADEQUACY
INFORMANT

1. SOURCES OF INFORMATION
2. RELATIONSHIP OF THE INFORMANT TO THE PATIENTS
3. INTIMACY AND LENGTH OF ACQUAINTANCE WITH THE PATIENT
4. RELIABILITY OF THE INFORMATION
5. GET INFORMATION FROM MORE THAN ONE SOURCE. AND
NOTE THIS SEPERATELY.
6. PSYCHOSIS- INFORMATION FROM OTHERS RELEVENT.
7. NEUROSIS - PERSON HIMSELF IS BEST.
CHIEF COMPLAINTS

 WHY THE PATIENT CAME TO THE CLINIC ?

 IN PATIENTS OWN WORDS
 FROM INFORMANT ALSO.
 CHRONOLOGICAL ORDER
 IN POINTS ( NOT A LONG LIST)
 OPEN ENDED QUESTION (What is the reason you have come
for?/ What brings you here?”)
 DURATION
HISTORY OF PRESENTING
ILLNESS.
 DETAILED ACCOUNT OF SYMPTOMS FROM ONSET TO THE TIME
OF CONSULTATION.
 IN CHRONOLOGICAL ORDER OF SYMPTOMS
 EXPLAIN ALL THE CHIEF COMPLAINTS MENTIONED ABOVE.
HISTORY OF PRESENTING
ILLNESS
1. ONSET-
a) ACUTE - WITHIN 2 DAYS
b) SUB ACUTE - WITHIN 1 WK
c) GRADUAL – WEEKS TO MONTH

2. DURATION-
3. COURSE OF ILLNESS –
d) EPISODIC
e) CONTINUOUS
f) FLUCTUATING
Graphic presentation of the course of illness can often be very informative
HISTORY OF PRESENTING
ILLNESS
 4. PRECIPITATING FACTORS- (physical or
psychological)
 Ascertain in whether the events clearly preceded the illness or
were consequences of the illness (eg. Job loss following the
onset of a schizophrenic illness).
HOW ILLNESS HAS EFFECTED..

1. BIOLOGICAL FUNCTIONING –
a) SLEEP
b) APPETITE
c) WEIGHT
d) THIRST
e) BOWELS
f) SEX
HOW ILLNESS HAS EFFECTED..

2. OCCUPATIONAL FUNCTIONING
3. SOCIAL FUNCTIONING –
 PERSONAL RELATIONS
4. DAILY FUNCTIONING –
 TYPICAL DAY.
 LIFE ACTIVITIES
5. PERSONALITY-
 DRESSING
 SPEECH
 INTEREST
 MOOD
 HABITS.
NEGATIVE HISTORY

 THOSE SYMPTOMS WHICH ARE NOT PRESENT IN THE PERSON.

 TO RULE OUT-

1. ORGANIC DISORDERS
o BRAIN INJURY – TRAUMA
o SEIZURES
o FEVER
o HEADACHE
o VOMITING
o HYPERTENSION
o DIABETES

2. SUBSTANCE ABUSE
NEGATIVE HISTORY..

3. DECREASED SLEEP 13. INCREASED ACTIVITY

4. DECREASED APPETITE 14. INCREASED TALK
5. WEIGHT LOSS 15. EXTRAVAGANCE

6. DECREASED ENERGY 16. INCREASED SEXUAL

INTEREST
7. DECREASED INTEREST
17. AUDITORY HALLUCINATION
8. DEPRESSION
18. VISUAL HALLUCINATION
9. DECREASED ATTENTION
19. TACTILE HALLUCINATION
10. HOPELESSNESS 20. DELUSIONS
11. SUICIDAL THOUGHTS 21. FEAR
12. SUSPICIOUSNESS 22. PANIC ATTACKS
PAST HISTORY

1. PAST PSYCHIATRIC HISTORY

2. PAST MEDICAL HISTORY
3. ALCOHOL AND SUBSTANCE ABUSE
HISTORY
PAST PSYCHIATRIC HISTORY

1. NATURE OF EACH ILLNESSESS

2. DURATION OF EACH ILLNESS
3. TREATMENTS RECEIVED
4. PATTERN OF RESPONSE
5. . 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 episodes of a
manic-depressive illness).
6. COMPLIANCE TO MEDICATION
7. RESIDUAL SYMPTOMS IF ANY.
TREATMENT HISTORY

 WHAT TYPE OF TREATMENT ( allopathic, homoeopathy,

Ayurveda, siddha, unani, faith healers )
 FROM WHERE
 LIST OUT THE MEDICINES
 RESPONSE TO TREATMENT
 SIDE EFFECTS
 COMPLIANCE
 BEHAVIOUR AT THE TIME OF HOSPITAL IP SETTINGS
FAMILY HISTORY

1. FAMILY TREE CONTAINING PATIENT’S

PARENTS AND PATIENT’S OWN FAMILY
FAMILY HISTORY

2. DESCRIPTION OF INDIVIDUAL FAMILY MEMBERS (father,

mother, siblings..)
 Whether living or dead
 Age of the death
 Education
 Marital status
 Personality
 Relationship with the patient
FAMILY HISTORY

3. HISTORY OF MENTAL ILLNESS- EPISODIC, OR CONTINUOUS

4. EPILEPSY, SUBSTANCE ABUSE, ALCOHOLISM, MENTAL
RETARDATION
5. SOCIO- ECONOMIC CONDITION OF THE FAMILY
6. LEADERSHIP PATTERN
7. ROLE FUNCTIONS
8. DECISION MAKINGS
FAMILY HISTORY

9. COMMUNICATION PATTERN IN THE FAMILY

10. SOCIALIZATION PATTERN WITH OUTSIDE
11. FAMILY ATMOSPHERE (formal, rigid, friendly, and aloof )
12. HOW THE PATIENT WAS TREATED BY THE FAMILY
13. TO WHOME THE PATIENT IS MORE ATTACHED
1. PERSONAL HISTORY
BIRTH AND EARLY DEVELOPMENT

a) FULL TERM OR PREMATURE PREGNANCY

b) TYPE OF DELIVERY
c) BIRTH COMPLICATION
d) BIRTH CRY
e) INFANT – MOTHER RELATION SHIP
f) PROBLEMS WITH FEEDING AND SLEEP
g) DEVELOPMENTAL MILE STONES
h) BEHAVIOUR PROBLEMS
i) ANY PHYSICAL ILLNESS
PERSONAL HISTORY..
2. CHILDHOOD

1. FEATURES OF ANXIETY:
a) SLEEP DISTURBANCE
b) THUMB SUCKING
c) NAIL BITING
d) TEMPER TANTRUMS
e) BED WETTING
f) STAMMERING
g) TICS AND OTHER MANNERISMS
PERSONAL HISTORY..
2. CHILDHOOD

2. CONDUCT DISTURBANCES
a) FREQUENT FIGHTS
b) TRUANCY
c) FIRE SETTING
d) STEALING
e) CRUALITY
f) LYING
3. RELATIONSHIP WITH PARENTS, SIBLINGS, AND PEERS.
4. PHYSICAL ILLNESS
 PERSONAL HISTORY..
3. SCHOOL
a) age of beginning and finishing school
b) , type of school attended
c) scholastic performances
d) attitudes towards peers and teachers
e) . Indications of learning difficulties
f) school phobia
g) Avoidance
h) Truancy
i) adjustment difficulties
j) extra-curricular activities
k) pattern of coping
PERSONAL HISTORY..
4. ADOLOSCENCE

a) peer group involvement and pressure

b) pressure to conform
c) substance abuse
d) sexual knowledge
e) MENSTRUAL HISTORY
PERSONAL HISTORY..

5. OCCUPATIONAL HISTORY
6. SEXUAL HISTORY
7. MARITAL HISTORY
PREMORBID PERSONALITY

 personality before the onset of the illness.

 Attitudes to others in social, family as sexual relationships:
 Attitudes to self
 Moral and religious attitudes and standards
 Leisure activities and interests
 Reaction Pattern to stress
 Biological functions and Habits
THANK YOU…….