Western Visayas Regional Hospital

MENTAL HEALTH UNIT

Pototan, Iloilo

(Guide for Case Clinical Conference)

PSYCHIATRIC REPORT

A. Psychiatric History

I. General Data: Name, Age, Civil Status, Nationality, Occupation, Address

II. Chief Complaint: Reasons for admission is recorded verbatim from the patient and from the
informant.
III. History of present illness: With organized, clear, complete, concise and accurate chronological
narration of the development of the current illness.
IV. Past History: Emotional or mental illness, extent of incapacity, type of treatment, names of
hospital, length of illness, effect of treatment.
_psychophysiologic disorders, fever, rheumatoid, arthritis, asthma, hyperthyroidism, Gastrointestinal
upset, recurrent colds, skin conditions.
_Medical condition following customary review of systems: use of alcohol or drugs.
_Neurological disorders history of craniocerebral trauma, convulsions or tumors.
V. Family History: Hereditary disease, history of mental illness important data and description of
members of the family that has been interacting (past and present),
relationship with them.
VI. Past Personal History: History (patients life from infancy to the present to the extent it can be
recalled, gaps in the history as spontaneously related to the
patient, emotion associated with these life periods, painful,
stressful, conflicts.
A. Prenatal Data:
_Age of mother when patient was born
_Superstitious and attitude of parents towards pregnancy
_Prenatal consultation and findings
_Previous deliveries, normal or abnormal

B. First Year of Life ( 0-1 ½ years):

_Primary socialization, oral phase, premature or normal, delivered at home or in hospital or other
places with or without assistance breast feeding, bottle feeding or mixed feeding until what age, with or
without schedule, upon demand, regular or irregular, was the child cuddled during feeding?
_Weaning: whether abrupt or by transition, methods used, age started, reaction of the child to weaning.
_Sucking: whether satisfactory or not, numbers of hours the mother stays with the child.
_If not the mother, who cares for the child and describe her personality.
_Was there nail biting, finchiness to food, temper tantrums?
_Age if dentition, crawling, first word uttered, learning to stand and walk, talking.

C. Toilet training: Anal Phase (1-3 years):

_Age when started, regular or left alone attitude
_Reaction of the child as scattering or playing with the feces
_Constipation, diarrheas, etc
_Attitude of mother towards cleanliness.
_Observe neurotic traits of child like bedwetting, tantrums, thumbsucking and nail biting.

D. Secondary socialization : Oedipal Phase (3-6 years):

_Plays with other children? Describe
_Does parents sleep with the children?
_Preference of the child to any of the parents and vice versa
_Attitude of parents to sex
_Misbehavior of the child
_Preference of the child for company (same or opposite Sex)

E. School History:
_Age when started schooling
_Reaction of the child during the first week at school adaptation to schoolmate, playful, friendly,
quarrelsome, timid, shy, withdrawn, a leader, a follower, bully or truant
_Level of education attained: reasons for dropping out, transfer or quitting school
_Intelligence and achievement

F. Home Environment
_Is home atmosphere happy, congenial, accepting, rejecting, etc.
_Transfer of residence-cause, reactions of the child
_Cause of family quarrel, whether overt, covert or concealed.
_Hobbies and habits of parents- alcohol, smoking, gambling, etc.
_The role of the grandparents in the house
_Favoritism in the family
_Evidence of over indulgence and over protection specially those close to the patient
_Philosophy, principles, practices and aspirations of the family

G. Interests, Hobbies, Habits:

_If active industrious, how leisure is spent, including social adaptability, interpersonal relationships with
family, neighbors and others. Any arrest authorities, drugs, alcoholism and smoking, etc.

VII. Marital History: Common- law marriages, legal marriages, length of courtship, age of marriage,
family planning and contraception; names and ages of children; problem of any family members,
housing difficulties.

VIII. Current Social Situation and Home Environment: Where does a patient live- slum, project, furnished
rooms, high crime neighbourhood, middle class neighbourhood, privacy of family members from each
other, sources of income is coming for children.

IX. Pre-morbid Personality- Make-up-behavior of patient before the start of mental illness.

B. Mental Status Examination

Consult glossary for definition of psychiatric signs and symptoms.

1. General Appearance and Behavior:

_Physical appearance: Height, dress, body hygiene, hair grooming.
 Does he appear appropriate to his occupation, shave, presence of beard or mustache?
_Facial expressions, body limb movements, mannerism, how to change the topic of conversation, staring
into space or to the examiner, eye to eye contact, head movements action as if listening to something.

2. Characteristics of speech: Of concern here is the form of talk rather its content.
_Quantitative abnormalities: incessant speech, flight of idea, scant monosyllable talk
_Qualitative abnormalities- Circumstantial perseveration, talk, neologism, clang association, senseless
punning, animal-like talk, affectations, stammering, stuttering, lipsing. Whenever possible record
adequate sample of abnormal talk verbatim.

3. Mood of affect: The level of and changes in feeling or a sensitive index of emotional illness. There are
many possible moods: Depression, elation, euphoria, anger, suspicious, fear, anxiety, panic, hostility,
calm, happiness, sadness, grief and combination of them.

Two factors must be evaluated to determine the patient’s feeling state:

1. Is the mood appropriate to the thought concern?
2. Is it a reasonable level of intensity? Bizarrely inappropriate moods may be observed in some patients
suffering from schizophrenia. Repressed patient may be excessive in degree. Patient with organic brain
may show fluctuation in mood in seemingly trivial stimuli, so called “Mood lability”. “Blunted” or
flattened affect may be seen in schizophrenia or brain damage (especially to frontal lobe and in a
particular form so called “ la belle indifference” in hysteria.
While the mood of some patients may be obvious, careful technique is required to solicit a true
start of affect in others. “Smiling depression” for example may be missed unless the examiner
specifically inquires about feeling of sadness, depression and ideas of suicide, as the patient may wear a
“euphoric façade”

IV. Content of thought (hallucination, faulty perceptions, delusion and misinterpretations, obsessive and
phobic ideas)

Distinguish what is directly presented and what is inferred, noting the basis of inference.
Delusions and hallucination should be described.
Hallucination and illusion effect any of the senses. Described their vividness and degree of reality not the
circumstances when they are most rare in true hallucinations.
If the auditory hallucinations are present and prominent, schizophrenia should be suspected. Visual and
tactile hallucinations are most often encountered in toxic states as delirium tremens, drug intoxication,
or deliria. Hallucination of other senses suggest the possibility of organic disease such as temporal love
epilepsy of tumor.
_Delusion and misinterpretation, Delusion are described as paranoid, magalomanic, or grandiose,
depressive, somatic, ideas of reference, and ideas of influence. An encapsulated delusion is difficult to
elicit unless the topic it relate is explored.
_Obsessive and phobic ideas: Know the different forms of phobia.

V. Sensorium Functions (Orientation, memory, learning, attention, fun of information, and intelligence)
_Orientation: Four areas of orientation to be explored:
1. Person- patient know who he is and the examiner/
2. Time- patient identify date and time of the day
3. Place- patient know where he is.
4. Situational orientation- Does the patient sense his surroundings and circumstances? Is he able not
merely to say where he is, who he is and when it is, but also behave congruently with his replies.
_Memory:
1. Rote Memory- multiplication table, nursery rhymes, familiar prayers.
2. Remote Memory- accounts of his past life as he remember it.
3. Recent Memory- What he did yesterday, what he did he does for breakfast, lunch or dinner.
4. Immediate retention and recall- ask the patient to repeat after your members of 3 digits, 4 digits,
etc.,then ask to repeat backwards. Most people can repeat 5 or 6 digits forward and 3 to 4 digits
backwards.

A simple and practical ways of evaluation orientation and memory administer

Khan’s 10 question mental status examination:

1. What is the name of this place?
2. Where is it located (address)?
3. What day of the week is it?
4. What is the month now?
5. What is the year?
6. How old are you?
7. When are you born (Month)?
8. When are you born( Year)?
9. Who is the president at present?
10. Who is the president before him?

_Attention and concentration- can attention be aroused and sustain?

Ask patient to subtract serially 7 from 100 or 4 from 25 are useful test of concentration. Telling days of
the week or months of the year in reverse order for poorly educated person.
_Fund of information and intelligence- should be geared to patients experience, and level of education.

Example of question for Information: Name Five(5) countries, Name Five (5) Presidents, etc.

VI. Insight and Judgement:

_Judgement-patient’s prediction of what he would do in imaginary situation.
_What you should do if you lost are in the woods.
_What you should do during fire inside the movie?
_Sight some proverbs and make the patient to interpret.
_Insight-degree of awareness and understanding of his illness.
_Are you mentally sick?
_Had you a nervous breakdown?

RELIABILITY: Make some comment the patient veracity or ability to report the situation, accurately.

C. Physical and Neurological Examination including Other Diagnostic studies:

1. Laboratory result: CBC, Urinalysis, serological test (STS), etc.
2. Other examination (EEG, etc)]
3. Psychological test results.

D. Hospital Course and Observation in the Ward:

This is a summary of progress notes, nurses notes, subsequent mental status of patient, and progress of
nurse-patient interaction with the patient.
N.B. Up to this point must be appeared in the protocol in abstract form.

E. Diagnostic Formulation of Nursing Impression:

1. Diagnostic classification according to the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders
_Nomenclature, classification, number, severity, chronicity, supplemental diagnosis to be ruled out.
2. Criteria for making the diagnosis: Behavioral symptoms, mental status, psychological test,
prepsychotic personality, physical examination, and laboratory.

F. Psychopathology: Based upn diagnosis, try to correlate theory (from references) with the actual case.
Site the predisposing and precipitating factors specific to the case.

G. Psychodynamics Formulation: Cause of patients psychodynamic breakdown, influence in patient’s life

that contributed to his present illness, environmental, genetic and personality factors relevant to
determining the symptoms.

H. Recommendations and Management:

1. Medical management
a. Drugs
b. Physical treatment.
2. Nursing Care Plan in tabulated form or paragraphs.
3. Discharge planning and follow up

I. Miscellaneous:
1. Objectives of case study
2. Evaluation in terms of objectives
3. Bibliography