SCHEME FOR CASE TAKING

Case-taking in psychiatry is both a Science and an art. 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 diagnosis and workout a management plan is an art, which should be mastered over
time. As in traditional medicine, perhaps to a greater extent, utmost 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. Investigation, 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 students to follow a uniform method of case taking. It has not been
possible to deal with all the areas exhaustively. Students are instructed to read texts cited in the
end to become more proficient in case taking.

HISTORY TAKING

Name: Age: Sex:

Education: Occupation:
Socioeconomic Status:

Informant:

Mention here the source of information, relationship of the informant to the patient, intimacy and
length of acquaintance with the 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: the
patient would be the best informant. When information is collected from more than one source,
do not collate the accounts of several informants in to 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 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 course. 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 weeks to few months).

(b) Precipitating factors: Enquire about any precipitating events. These could be physical (eg.a
febrile illness) or psychological in nature (e.g. Death / loss). Ascertain whether the events clearly
preceded the illness or were consequences of the illness 9e.g. Job loss following the onset of a
schizophrenic illness).

(c) Course of the illness: The course of illness can be episodic 9discrete symptomatic periods
with intervening periods of normalcy) continuous or 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

2/13 2/13 2/13

Age: 25 Yrs Age; 27 Years Present episode

Untreated No definite precipitating Age; 30 Yrs
Factor treated with antidepressants

(d)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.

(e)Negative history:
Lastly, certain historical details must be routinely enquired into, to rule out an organic aetiology.
These include; histories of trauma, fever, headache, vomiting, confusion, disorientation, memory
disturbance, and 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.

PAST HISTORY:
Enquire about both past physical illness, 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 episodes of a manic –
depressive illness).

FAMILY HISTORY:

Affected male, female Abortion

Index Patient
Unaffected
Consanguineous union Dead

Given 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. Enquire about
the physical and / or psychiatric illness in the family and record it in detail. Describe the socio-
economic condition of the family, leadership pattern, role functions, and communication within
the family.
PERSONAL HISTORY:

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 in home? Any complications during
delivery? Any physical illness during the post natal period? Ascertain whether milestones of
development were normal or delayed.
Behavior during childhood: Enquire about sleep disturbance, thumb sucking, nail biting,
temper tantrums, bed wetting, stammering, tics and mannerisms. Look for conduct disturbance in
the form of frequent fights, truancy, stealing, lying, and gang activities. Also enquire about
relationship with parents, siblings, and peers.
Physical illness during childhood: Record physical illness suffered in childhood. Enquire
specifically regarding epilepsy, meningitis, and encephalitis.
School: Enquire about age of beginning and finishing school, type of school attended, scholastic
performance, attitudes toward peers and teachers.
Occupation: Age of starting work, jobs held, in chronological order: work satisfaction,
competence, future ambitions.
Menstrual History: Enquire about age menarche; regularity of periods: dysmenorrhoea;
menorrhagia / oligomenorrhoea: emotional disturbance in relation to menstrual cycle.
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 hetero sexual fantasies, inclinations and experiences, extra marital
relationships.
Marital History: Enquire regarding age at 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 marital relationship, any separation or divorce. Note the number 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 description of the personality before the onset of the illness. Aim to
build up a picture of the individual, not a type, Enquire with respect to the following areas.

(1) Attitude to others in social, family and sexual relationships:

Ability to trust other; make and sustain relationship, anxious or secure, leader or follower,
participation, responsibility, capacity to make decisions, dominant or submissive, friendly
or emotionally cold, evidence of any jealousy, suspiciousness, guardedness, etc. Evidence
of difficulty in role taking – gender, sexual, familial, parental and work.
(2) Attitude to self; Egocentric, selfish, indulgent, dramatizing, critical, deprecatory,
over concerned, self conscious, satisfaction or dissatisfaction with work. Attitudes to past
achievements and failures, and to the future.
(3) Moral and religious attitudes and standards: Evidence of rigidity or compliance,
permissiveness or over conscientiousness, conformity or rebellion. Enquire specifically
about religious beliefs.
(4) Mood: Enquire about stability of mood: mood swings, whether anxious, irritable, and
worrying or tense. 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 or 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 excessive use
of the particular defense mechanism such as denial, rationalization, projection etc.
(8) Habits; 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
were obtained, they should be described in detail. It is not adequate to say ‘delusions
present’ or ‘hallucinations ++’. MSE has to be repeated for 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 not 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.

GENERAL BEHAVIOUR
Descriptions as complete, accurate life like as possible, of the observations ward staff and
your own. The following points may be considered, though not exclusively.
Enquire about the way of spending the day, eating, sleeping, and cleanliness in general,
self care, hair and dress. Behavior towards other patients, doctors and nursing staff. Does
the patient look ill? Note whether the patient is fully conscious, stupors or comatose. Is
he in touch with surroundings? Is the patient relaxed or tense and restless? Is he slow of
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
adequate eye contact? Does the patients’ behavior suggest that he is disoriented? Note the
presence of any tic or mannerisms? Note the presence of any catatonic phenomena.

PSYCHO MOTOR ACTIVITY:

Note if the psycho motor activity is increased , decreased or normal.

Talk;
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 of
excessive. Is it high toned or low toned? Is the tempo fast or slow? Is the reaction time
increased or decreased? Is the prosody of speech maintained? Is it relevant? Is coherent?

THOUGHT:
Examine thought processes with respect to :
Stream: Flight of ideas, retardation of thinking, circumstantiality, preservation, though
blocking.
Form: Presences of formal thought disorder.

Possession;
Obsessions and compulsions, thought alimentation. With respect to obsessions, elicit
their nature- ideas, doubts, imagery, impulses and phobias. Similarity clarifies 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 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 or poorly systematized and whether they are
mood congruent or not. Enquire about worries and preoccupations, hypochondriacally
and somatic symptoms. Depressive ideation, ideas of worthlessness, guilt, hopelessness
and suicidal ideas must be enquired and recorded.

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 emotions (happiness, sadness,
anxiety etc), the intensity or depth emotional experience, the range of affective responses,
mobility, reactivity (changes in emotion in relation to environmental factors) diurnal
variations, congruity (in relation to thought processes) and appropriateness (in relations
situations). Note any evidences of lability (rapid and extreme changes in emotions.

PERCEPTION:
Record the presence of illusions and hallucinations. Enquiry should be made into the
following modalities; vision, hearing, smell, touch, 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, synaesthesia and autoscopy. Detailed description of the actual experiences
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 voice/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:
reactions to the hallucinations whether mood congruent. Distinguish hallucinations from
imagery and pseudo-hallucinations.
Others perceptual disturbance that must be enquired into include heightened perceptions,
dulled perception, depersonalization experiences, and disturbance in the perception of
time.
COGNITIVE FUNCTIONS: (Detailed section given after the final formulation):
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 terms (partial insight)? Does he fully realize the emotional nature
of this illness and the cause of his symptoms(Insight present)?

SUMMARY

The purpose of a summary is to provide concise descriptions of all the important aspects
of the case to enable others who are unfamiliar with 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 student’s own assessment of the case rather than a restatemtn of the facts. Its
length, layout and emphasis will vary considerably from one patient to another. It should
always include a discussion of the diagnoses, of the etiological factors which seem
important, a plan of management and a estimate of the prognosis. Regardless of the
uncertainty or complexity of the case, a provisional diagnosis should always be specified
using the ICD.
 INVESTIGATION TREATMENT AND FOLLOW UP
Biomedical, radiological or psychometric investigations should be carried 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.

FINAL FORMULATION
This is a revision of the initial formulation drawn up at the time of discharge. It should
specify any divergences of opinion and should state the views of the consultant clearly. It
should be written in the light of the patient’s response to treatment and other information
becoming, available since the time of admission. Its length and layout will vary
considerably but it should always include a final diagnosis, with amplifying comments
and an estimate of the prognosis.
CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS;-
Clinical assessment includes the areas of
1. Orientation
2. Attention and concentration
3. Memory
4. Intelligence
5. Abstraction
6. Judgment
7. Insight

ORIENTAION:
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, year) today?
Place:
1.What place is this? (if the answer is not forthcoming, a specific question is )
2. Is, this a school, office, hospital, restaurant etc..? If patient says it is a hospital details may
be asked depending on background)

Person:
1. Orientaion to self is tested by asking the identity of the patient
2. Inquiring about the identity of the patients 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 instructions; 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 instruction the patient.
i) Give an example(for example if I say 3,7 you say 3,7)
ii) Reads digits at the role of one per second to the patient
iii) 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
4-7-2-9-1-6-2-5 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 repeat them after me in a reversed order for example if I say 2-5, you
have to say 5-2. The procedure is the same as for digits forward:
- The same digits be repeated not be used as for the forward test
- No digit backward score is the highest number of digits correctly recalled
backward after a maximum of 2 trials.

SERIAL SUBSTRACTIONS:
Increasingly difficult tests are presented. The examiner a) instructs the patient, b) gives an
example of how to perform task, c) notes the response 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:

I) Address test. An address consisting of about 4-5 facts, which 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
c) 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 or any cross-checked from reliable source.
d) 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 or death or any family members
V) year of completing education
4-5 facts may be asked for relevant to the patients background and answers should
be cross checked.

INTELLIGENCE
This includes the areas of general information, comprehension, arithmetic and vocabulary,
General information; information relevant to the patient’s literacy age or occupation may be
asked e.g in literate.
a) Name of Prime Minister
b) 5 rivers, 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 is questions asked during an interview is on 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 it rains when you start in 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 that it will be late by the time
you read 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 (or
25 paisa)?
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)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, is always presented before similarities.
Difference:
The instructions are as fallows; I will be presenting to you some parts 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 – audio0
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 it 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 - so shall you reap
4. All that – is not gold or all that is while is not milk
5. Where there is a will there is a way
6. Empty – make more noise
7. Every – praises his pot
8. It is useless to cry over spilt milk

The responses of the patient is to be noted verbatim and judged to be correct / incorrect

JUDGEMENT:
Is assesses in the following areas
1) Personal
2) Special
3) Test
Personal : - Judgment is assessed by inquiries about the patient future plans
Social :- Judgment is assessed by observing behavior in social situations
Test :- 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? 9correct answer – try to put if off with water)
2. Letter problem; if when you are walking on the roadside you see a slumped &
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-COOPERATIVE 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 reactions is during the
period of negativism, the time of study a stupor is during the stuporsphase.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 coven in a systematic way the important points for purposes of
clinical differentiation.

1. 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 of playfulness, mischievousness or
assaultiveness.
Defense movements when interfered with or when prick with pin eating and dressing
attention to bowels and balder. Do the movements show only initial retardation or are
the consistent throughout?
f) To what extent does the attitude change? Is the behavior occurrences influence the
condition.
2. FACIAL EXPRESSION
Alert, attentive, placid, vacant, stolid, sulky scowling, averse, perplexed, distressed, etc.
any play of facial expression on sings of emotions: tears smiles, flushing, and
perspiration. On what occasions?

3. EYES:
Open or closed, if closed, 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
gazing figure glances or evasion. Rolling of eyeballs upwards. Blinking, flickering,or
tremor of lid. Reaction to sudden approach of threat to stick pin in eye. Sensory reaction
of pupils (dilation from painful stimuli or irritation to skin or neck.)
4. REACTION TO WHAT IS SAID OR DONE:
Commands: show tongue, move limbs, grasp with hand (clinging clutching, etc) Motions
slow or sudden, reaction to pin-pricks. Automatic obedience: tell patient to protrude the
tongue to have in stuck into it.
Exhopraxia; imitation of actions of others.
5. MUSCULAR REATIONS:
Test for rigidity: muscles relaxed or tense when limbs or body is moved.
Catalepsy, waxy flexibility, negativism shown by movements in opposite direction or
springs or cogwheel resistance.

REFERENCES:

 Hamilton, M (E)
 Fish’s clinical psychopathology; signs and symptoms in psychiatry.
 John wright and sons Ltd. Briston 1974.
 Hamilton, M. (Ed)
 John writht and sons Ltd. Briston 1974
 Jaspers, K
 General psychopathology. (Translations by J.Hoeing and W.M.Hamilton)
 Manchester University Press, 1963.
 Strub, R.L. & Black, F.W. (Eds)
 The Mental Status Examination in Neurology.
 F.A.Davis Company, Philadelphia 1977.