Psychiatric Case History & Mental State

Examination

DR : ZIAD ARANDI
AL-NAJAH NATIONAL
NAL UNIVERSITY / NABLUS
NAB

/
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(Psychiatric Case History)
( Personal Information )
:(Age) *

: (Name) *

:(Residency) *

:(Sex) *

:(Marital State) *

:(Job) *

: ( Referral )
: ( Referred From )
: ( Cause Of Referral )

: ( Chief Complaint )
Complaint

Duration

:(History Of Present Illness)

:(Time Of Onset)
:(Duration)
(Suddenly) * :(Mode Of Onset)
(Gradually) *
:(Circumstances At Onset)
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:(Fluctuations)
:(Improved By)
:(Worsened By )
: ( Impact On Self )
: ( Impact On Others )
: ( Associated Disturbances )
( Sleep )
( Appetite )
( Sexual Drive )

: ( Family History )
: ( Father )
: ( Age Or Date Of Death )
: ( Age Of Death )
: ( Cause Of Death )
: ( Health )
: ( Occupation )
: ( Personality )
: ( Relation To Patient )

: ( Mother )
: ( Age Or Date Of Death )
: ( Age Of Death )
: ( Cause Of Death )
: ( Health )
: ( Occupation )
: ( Personality )
: ( Relation To Patient )

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: ( Siblings )
: ( Number & Name(s) )
: ( Age(s) )
: ( Occupation(s) )
: ( Marital State(s) )
: ( Relation To Patient )

Psychiatric & Neurological Disorders )

: ( In The Family
: ( Psychiatric Disorders )
: ( Personality Disorder )
: ( Epilepsy )
: ( Alcoholism )
: ( Other Neurological Disorder )
: ( Abnormal Movement )
: ( Migraine )

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:(Personal History)
:(Early Development )
: (D.O.B)
: (Place O.B )
: (Weight At Birth)
:(Abnormality During )
(During Pregnancy )
(During Birth)
:(Difficulties in Habit Training (delays))
: (Achievement Milestones)
(Walking )
(Talking )
(Sphincter Control )

: (Behavior during childhood)

(neurotic traits)
(nail biting )
( thumb sucking )
(bed wetting )
(fear )
(sleep difficulties )

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: (school)
(Age began)
(age finished)
School (Private or Governmental) ( )
(Prolonged absence)
(Years repeated)
(Specific difficulties)
(friends )
(Attitude to peers and teachers)
(Examinations)
(Qualifications)
(Higher education)

:(Occupation)
:(current job)
:(duration)

: (place)

: (type)
:(satisfaction)

:(Chronological list of jobs)

:(duration)

:(place)

:(type)
(satisfaction)

:(reason for changing)

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(Psychosexual history)
(Age of puberty)
(menstrual cycle)
(menopause )

(menarche)
(regulation)

(emotional disturbance )
:(Masturbation)
(any sexual disorder or deviation )

: (Marital history)
(duration)
( Spouse age)
(occupation)
(character )
(plans for the future )
(relationship)
(Past separations and divorces)

(Past psychiatric Hx)

(type )
(date )
(treatment)
(hospitalization)
(names of doctors )
(diagnosis)
(physical health )
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:(Forensic history)
(charges )
(Court appearance)
(Probation orders )
(Social conditions)
:(home )
: (with whom )

: (where)
: (work )

: (with whom )

: (where)
: (Leisure )

:(with whom)

: (where)

: (financial circumstance)
(Satisfaction )
( Dissatisfaction )

(Evidence of emotional conflict in)

(family ) o
(Work) o

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: (Personality)
: (Attitude To)
(Family)

(Society)

(Morals)

(Opposite Sex)

(Standards)

(Religions)

: (Addiction)
: (Alcohol)
: (Past)

: (Currently)
:(How Often)
:(How Much)
:(How Long)
: (Any Withdrawal Symptoms)
:(Complications)
(Tobacco/Drugs) /

: (Past)

(Currently)
:(How Often)
:(How Much)
:(How Long)

:(Any Withdrawal Symptoms)

:(Complications)
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( Mental State Examination)

(General appearance & Behavior )-:
:(Gait)
(Special Character)

(Slow)

(Fast)

:(Clothes)
( Self-Neglected)
-: (Usual or Unusual)

(Occasion)

(Color)

(Combination)

: (Appropriate for)

(Sex)

(Age)

:(Motor Activity)
(Usual)
: (Unusual)
(Underactive)

(Overactive)

(Abnormal Form)-:Ticks, Mannerism, Stereotypes

(Social Manner):
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(Increased) ( Diminished) ( Appropriate)

:(Facial Expressions)
(Mouth)(Eyebrows) -

(Hair) -

-(Head) -

(Affect) -(Skin Of Face) :(Eye Contact) (Avoidant)

(Gazing to Ground)

(Good Or Poor)

-: (Body Posture)
(Leaning Forward) ( Upright)

(Limb Movements):
(Kept Close To Body)
(Hand Tremor)
(Gesture Movements)
(Shoulders & Arms Held Rigid)

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(Speech)-:
(Speed/Rate) :
(Fast)

(Slow)

(Normal)

(Quantity) :
(Much)(Little)(Normal)

(Volume)-:
(Loud)

(Low)

(Normal)

-:( Tune )
(High Pitch)

(Low Pitch)

(Normal)

(Speech Topics):
(Vagueness)( Word-Salad)
(Poverty Of Thoughts)( Flight Of Ideas)
(Dissociation) ( Pressure Of Speech)
(Whispering)( Muttering)
(Neologism)( Shouting)

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-: ( Mood )
:(Subjective & Objective)
(Ecstasy)( Euphoric) ( Elated) ( Cheerful) (Happy)
(Suicidal)( Despair)

(Depressed) (Sad) ( Unhappy)

(Panic) (Phobic)( Fearful) (Irritable) ( Tense) (Anxious)

:(Sleep)
(Early)

(Mid)

(Late And Feeling On Getting Up)

(Diurnal Variation)
(Appetite)
(Bowel Disturbances)
(Weight)
(Interests)
(Enjoyment)
(Libido)

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-:(PreoccupationalThoughts)
(Morbid Thoughts)

(Worries)

(Obsessional thoughts)

(Suicidal thoughts)

-: (Thought Disorders)
: (Content)

-: ( Delusions Types)
(Delusions of passivity)
(Delusions of influence)
(Delusions of thought reading)
(Delusions of thought insertion)
(Delusions of thought withdrawal)
(Persecutory delusions)
(Grandiose delusions)
(Jealous delusions)
(Somatic delusions)
(Delusions of guilt)
(Delusions of control)

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-: Disorders of Perception
:(Hallucinations)
Visual Hallucinations

Auditory Hallucinations

Olfactory Hallucinations

Tactile Hallucinations

Gustatory hallucination

(Illusions)
(Derealization)
(De Javu)
(Depersonalization)

(Awareness of disturbance in ) :

(Thinking)

(Blocking)

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-: (Cognitive Functions)
-: (Orientation to)
- :(Time)
(Date)

(day)

(Season)

-: (Place)
(Location now)

(City Location)

(Home Address)

-:( Person)
: (Name)

: (Age)

(More than 2 errors = disorientation accordingly) )

-: (Attention & concentration)

( Months of Year ) ( Serial seven test)
( )
(More than 2-3 errors, or more than 2 minutes may indicate impairment)

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-: (Memory)
: ( Short-term Memory )
: ( Verbal )
( Digits Spans Forward & backward )

109

56318

729416

8294175

51964278

759318260

N.B. ranges (7+2)

: ( non verbal )
( Visual memory )

: (Intermediate memory )
( Name & Address )

Mr. John Edwards

67 Melbourne grove
London SE 25
N.B. ranges (1-2)

: ( Long-term memory )
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( Personal )

( Historical )

-: (intelligence)
: (Proverbs)
( A stitch in time saves nine ) o
( No use crying over spelt milk) o
People in glass houses ) o
( should not throw stones

-: (Insight)
Has insight

Partial insight

No insight

( Illness: (mental, physical, and nervous) :

( Does he think he needs treatment ? )

( Difficulties )

( Prospects )

-: (The interviewer's reaction to thepatient)

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2015-2014
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