Dr.

BABASAHEB AMBEDKAR MARATHWADA UNIVERSITY AURANGABAD

DEPARTMENT OF PSYCHOLOGY

PSYCHIATRIC CASE HISTORY

Date……………………………………. Roll Number………………………………………………

Student’s name………………………………………………………………………………..

Bio-data of the patient

 Name:…………………………………………………………………………………………………………………..

 Age: :…………………………………………………………………………………………………………………..

 Sex: :…………………………………………………………………………………………………………………..

 Marital status: :…………………………………………………………………………………………………………………..

 Educational status: :…………………………………………………………………………………………………………………..

 Occupation: :…………………………………………………………………………………………………………………..

 Religion: :…………………………………………………………………………………………………………………..

 Caste: :…………………………………………………………………………………………………………………..

 Residence:…………………………………………………………………………………………………………………..

 Permanent address: :…………………………………………………………………………………………………………………..

Source of referral:

 Informant

Name…………………………………………………………………………………………………………..

Age……………………….relationship…………………………………………… Reliability of information:

 Adequacy of information:…………………………………………………………………………………..

PRESENTING COMPLAINTS (with duration)

 Patient’s:………………………………………………………………………………………………………………………………………
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  Informant’s:…………………………………………………………………………………………………………………………………
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HISTORY OF PRESENT ILLNESS:

 Onset, duration and mode of

onset:……………………………………………………………………………………………………………………………………………
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 Precipitating factor:
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 Course of illness continuous or episode or with

exacerbations:………………………………………………………………………………………………………………………………
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 Progression of severity: ……………………………………………………………………………………………………………

 Treatment history and its effect on course and severity of illness:

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PAST HISTORY

 Psychiatric: ……………………………………………………………………………………………………………………………

 Medical:………………………………………………………………………………………………………………………………

FAMILY HISTORY

Patient’s family or origin. Describe with a family chart. Presence or absence or mental illness, alcohol or
drug abuse among close relatives. Relationship among them; quality of relationship; family dynamics.

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PERSONAL HISTORY

 Birth ……………………………………………….

 Events during pregnancy ………………………………………………………………………………………….

 Birth weight ………………………………………………………………………………………………………………

  Events after birth:

crying, ⃝ breathing, ⃝ cyanosis ⃝ high temperature ⃝ convulsions ⃝

 Milestones: motor psychosocial…………………………………………………………………………….

 Presence of neurotic symptoms: e.g. thumb sucking ⃝ bed wetting ⃝ temper tantrums ⃝

 Sexual history:………………………………………………………………………………………………………………………….

 Menstrual history: ……………………………………………………………………………………………………………………

 Work history: …………………………………………………………………………………………………………………………..

 Patient’s family:

Marriage ⃝ children………………. Relationship………………………………………………………………..

presence of mental illness or alcohol or drug abuse. ………………………………………………………

PREMORBID PERSONALITY

 Traits: important habits; general mood; attitude towards work, family, morality; relationship
towards family, friends, relatives, colleagues; religiosity; description of the patient before onset
of illness.

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EXAMINATION OF PATIENT

Physical examination:

 General:……………………………………………………………………………………………………………………………..

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MENTAL STATE EXAMINATION (for cooperative patients)

1. General appearance and behavior:

(Describe the patient: built, appearance, age group, grooming, hygiene, dress, level of cooperation, level
of communication, psychomotor activity, overall behavior during interview, catatonic features, or any
other abnormal movement.)

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 1. Speech or talk:

(Spontaneous or non-spontaneous; reaction time; tone; pitch; volume; language; understandable.

Description of the physical quality of the talk.)

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1. Mood:

Subjective: in patient’s verbatim

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Objective (also called “Affect”): examiner’s assessment: predominant mood; any variation; reactivity;
congruency to thought or situation; or any other
abnormality………………………………………………………………………………………………………………………………………………
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1. Thought: ……………………………………………………………………………………………………………………………………..

2. Form of thought: …………………………………………………………………………………………………………………..

3. Content of thought:

Preoccupation ⃝ abnormal ideas ⃝ delusion ⃝ obsession ideas ⃝ depressive ideas ⃝

4. Progression of thought: ……………………………………………………………………………………………………….

5. Perception:

Illusion ⃝ hallucination ⃝ perceptual abnormalities ⃝

1. Attention and concentration:

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(Give examples. Serial 7s: 100 minus 7 test; Serial 3s: 30 minus 3; counting till 20 and reverse; names of
months and days forward and then reversing; mistakes committed; time taken; perseveration, etc.)

1. Memory: …………………………………………………………………………………………………………………………..

2. Immediate: ………………………………………………………………………………………………………………………

1. Recent: (of a few hours or 1–2 days) ……………………………………………………………………………………….

Ask about food items taken especially vegetable this morning and last night. Events happened or
visitors’ name at home or in the hospital.

1. Remote or past:

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Major happenings in patients’ life e.g. marriage, passing of SLC, birth of children, major national events
like earthquakes, floods, change of governments, pro-democracy movements, etc.

1. Intelligence:

(Average or below average)……………………………………………………………………………………………………………………

1. Judgment: ……………………………………………………………………………………………………………..

2. Social: behavior during interview and other social settings……………………………………………………..

1. Grasp of general knowledge: …………………………………………………………………………………………….

1. Insight:…………………………………………………………………………………………………………………………….

FORMULATION OF THE CASE

 Particulars of the patient

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 Summaries of history and examination

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 Possible causative factors

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 Precipitating factor

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 Course of illness ………………………………………………………………………………………………………………………..

  Consequences on personality, personal life, family, society,
etc…………………………………………………………………………………………………………………………………………………
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Provisional diagnosis:

1. In ICD-10 system …………………………………………………………………………………………………………………..

2. In DSM-IV system …………………………………………………………………………………………………………………..

Differential
diagnosis:……………………………………………………………………………………………………………………………………………
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Management plan:

 Physical: investigations (EEG and others), medicines

 Psychological: psychotherapy, behavior therapy, etc.

 Social: family therapy, assistance in housing, living, marriage, relationship, employment, etc.