NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS

SCHEME FOR CASE TAKING

1. History
2. Mental status examination
3. Physical examination
4. Summary
5. Formulation
6. Investigations, treatment & follow-up

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.

HISTORY TAKING

Name :

Age : Sex :

Socio-economic status :

Informant:

Mention here the source of information, relationship of the informant to the patient,
--------------------------- 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 illness like
psychoses, relatives will be able to provide more reliable information while in neurolic illness, the
patient would be the best informant when information is collected from more than one source, do
not collage the accounts of several informants into 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 other complaints, others might not spontaneously report their difficulties unless
more direct questions are posted. 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 Abrupt (within 48 hrs) acute (i.e., developing
within few hours – 2 weeks or insidious (few weeks to few months).
b) Precipitating factors: Enquire about any precipitating events. These could be organic (of
febrile illness) or psychological in nature (e.g. death/loss). Ascertain whether these ------------- had
preceded the illness or were consequences of the illness (e.g. job loss, following the onset of a
schizophrenic illness).
c) Course of the illness: The course of an illness can be episodic (discrete symptomatic periods
with intervening periods of normacy, continuous or fluctuating (periodic exacerbations of a
continuous illness). Also a different pattern of symptoms may evolve in a continuous prominent.
Graphic presentation of the course of illness can often be very informative, as shown below.
1
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS

Financial loss Got married

2/12 2/12 2/12

Age: 25 yrs Age: 27 yrs 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.

Lastly, certain historical details must be routinely enquired into, to rule out an organic aetiology.
These include: history of trauma, fever, headache, vomiting, confusion, disorientation, memory
disturbance, history of physical illness 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.

Give 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 ----------) education,
occupation, marital status, personality and relationship with the patient. Describe the socio-economic
condition of the family, leadership pattern, role functions and communication with the family. Enquire
about the physical and or psychiatric illnesses in the family and --------------- it in detail.

2
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
PERSONAL HISTORY

1. 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 at home? Any complications during
delivery? Any physical illnesses in the post natal period? Ascertain whether milestones of
development were normal or delayed.

2. Behaviour during childhood: Enquire about sleep disturbances, thumb-sucking, nail-biting,

temper tantrums, bed wetting, stammering, tics and mannerisms. Look for conduct disturbances in
the form of frequent fights, truancy, stealing, lying and gang activities. Also enquire about relationship
with parents, siblings and poors.

3. Physical illness during childhood: Record physical illnesses suffered in childhood. Enquire
specifically regarding meningitis and encephalitis.

4. School: Enquire about age of beginning and finishing school, type of school attended,
scholastic performance, attitudes towards peers and teachers.

5. Occupation: Age of starting work, jobs holding chronological order, work satisfaction,
competence, future ambitions.

6. Menstrual history: Enquire about age of menarche, reaction to menarche, regularity of

periods; dysmenorrhoea, menorrhagia/oligomenorrhoea; emotional disturbances in relation to
menstrual cycle.

7. 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 heterosexual fantasies, Inclinations and experiences, extramarital relationships.

8. Marital history: Enquiry 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.

9. Use and abuse of alcohol, tobacco and drugs: Enquire about smoking and drinking pattern
and abuse of other drug like cannabis, opiates, barbiturates etc.,

PREMORBID PERSONALITY

In this description of the personality prior to the beginning of the mental illness, do not be satisfied
with a series of adjectives and epithets, but give illustrative anecdotes and detailed statements. Aim
at a picture of an individual, not a type, the following is merely a collection of hints, not a scheme. It
will not be possible to cover all the items listed in the course of the first interview, but an attempt
should be made particularly cases of neurosis or affective disorder, to elicit evidence about all aspects
of pre-morbid personality in the course of explorations extending over a period.

3
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
1. Social relations: The family (attachment, dependence); to friends, groups, societies, clubs to
work and workmates (leader or follower. Organizer, aggressive, submissive, ambitions, adjustable,
independent).
2. Intellectual activities: Hobbies and interests books, pictures, preferred, memory, observation,
judgement, critical faculty.
3. Mood: Bright and cheerful or despondent, worrying or placid; strung or calm and relaxed;
optimistic or pessimistic; self-depreciative or satisfied; mood stable or unstable with or without any
occasion.
4. Character:
a) Attitude to work and responsibility: welcomes or is worried by responsibility, makes deisions
easily or with difficulty; haphazard and slapdash or methodical and meticulous; rigid or flexible;
cautious, foresightful and given to checking or impulsive and slipshod; preserving and determined or
easily bored discouraged.
b) Interpersonal relationships: Self-confident or shy and timid, insensitive or touchy and sensitive
to criticism, trusting or suspicious and jealous, emotionally-controlled or quick-tempered and
irritable, tactful or outspoken; enjoys or shuns self-display; quiet and restrained or expressive and
demonstrative in speech and gesture; interest and enthusiasms sustained or evanescent, tolerant or
intolerant of others; adaptable or rigid.
5. Energy & Initiative: Energetic or sluggish, output sustained or fitful, fatiguability, any regular
or irregular fluctuations in energy or output.
6. Fantasy life: Frequency and content of daydreaming.
7. Habits: Eating (fads); alcohol consumption; self-medication with drugs or -------- medicine,
specify amounts taken recently and earlier tobacco consumption; sleeping; excretory functions.

MENTAL STATUS EXAMINATION (MSE):

A systematically conducted mental status examination is an important component of case taking it is
essential or records the observations properly. Whenever positive findings are obtained, they should
be described in detail. It is not adequate to say ‘delusions present’ or ‘hallucinations’. MSE has to be
repeated 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 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.

1. GENERAL BEHAVIOUR:
Description as complete, accurate, life like as possible, of the observations of ward ---------- and your
own the following points may be considered though not exclusively.

Enquiry about the ways of spending the day, eating, sleeping,

-------------------------------------
Patient’s behaviour suggest that he is oriented/disoriented. Note the presence of any lies or
mannerisms. Note the presence of any catatonic phenomena.

2. PSYCHOMOTOR ACTIVITY:
Note if the psychomotor activity is increased, decreased or normal.

3. SPEECH:
4
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
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 or escessive? 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 it coherent?
Describe under these headings; relevance, coherence, volume, tone, tempo, reaction time.

4. THOUGHT:
Examine thought processes with respect to
Form: Presence of format thought disorder
Stream: Flight of ideas, retardation of thinking circumstantially, preservation, thought blocking.
Possessions: Obsessions and compulsions, thought alienation. With respect to obsessions, elicit their
nature-ideas doubts, imagery, impulses and phobias. Similarly clarify the nature of compulsive acts
checking, counting or washing are these ‘controlling’ compulsions of ‘yield--------- 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 ideation, ideas of worthlessness,
guilt, hopelessness and suicidal ideas must be enquired and recorded.

5. 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 or emotion (happiness, sadness, anxiety etc), the intensity or
depth of emotional experience, the range of affective responses, reactivity (changes in emotion in
relation to environmental factors), diurnal variation, cenguity (in relation to thought processes) and
appropriateness (in relation to situations). Note any evidence of liability (rapid and extreme changes
in emotion).

6. PERCEPTION:
Record the presence of illusions and hallucinations. Enquiry should be -----------
----------------------------------------------
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 to hallucinations; whether
mood congruent. Distinguish hallucinations from imagery and pseudo-hallucinations.
Other perceptual disturbances that must be enquired into include heightened perception, dulled
perception, de presonalization/de realization experiences in the perception of the -----------

7. COGNITIVE FUNCTIONS: (Detailed section given later):

CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS
Clinical assessment includes the areas of
5
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
1. Orientation
2. Attention and Concentration
3. Memory
4. Intelligence
5. Judgement
ORIENTATION
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 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:
a) Orientation to self is tested by asking the identity of the patient.
b) Inquiring about the identity of the patient’s 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. The 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 instructing the
patient.
i) Gives an example (for example if I say 3, 7 you say 3, 7)
ii) Reads digits at the rate 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
5-3-3-7 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
4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4
The digit span is the highest number of digit 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

6
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
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. This procedure is 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 ----------------- after a
maximum of 2 trials.

2. Serial subtraction
Increasingly difficult tests are presented. The examiner a) instructs the patient, b) gives an example of
how to perform task, c) notes the responses verbatim and d) notes the time taken in seconds.
TASK: Correct response and the limit
20-1 20 to 0 reversed in 15 seconds
40-3 40,37,34,31 etc in 120 seconds
100-7 100,93,86,79 etc in 120 secs

3. Days or months forward to backward

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 convesation (to avoid rehearsal) and the response is noted verbatim.
Recall is asked for after 3-5 minutes.
ii) Asking the patient ro recall events in the last 24 hours e.g. details of the time and amount o]in
a meal, visitors to the hospital from an inpatient. Responses given by the patient should be noted of
any cross-checked from reliable source.

c) Remote memory: Information on life events

i) Date of birth
ii) Number of children
iii) Names and number of family members
iv) Time since marriage or death or any family member
v) Year of completing education

4-5 facts may be asked for relevant to the patient’s 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 patients literacy age or occupation may be asked e.g. in
literate
a) Name of prime minister
7
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
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 ow-index. Speci------------- the
following questions of increasing difficulty may be asked.

1. What will you do when you feel cold?

2. What will you do if it rains when you start to 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 ready 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
paise)?
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) 8, 5) 3

Abstraction:
Tested by a similarities, differences and proverbs
Similarities: The patient is given the following instructions.

8
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
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)
Colrrect responses i.e., abstract responses are given in brackets.

Differences being an easier task, is always presented before similarities.

Difference:
The instructions are as follows: 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-audio)
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 sow, so shall you reap
4) All that glitters is not gold or all that is white is not milk
5) Where there is a will there is a way
6) Empty vessels make more noise
7) Every pollar praises his pot
8) It is useless to cry over spit milk

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

JUDGEMENT:

Is assessed in the following areas.

1) Personal
2) Social
3) Test
Personal: Judgement is assessed by inquiries about the patient future plans
Social: Judgement is assessed by observing behaviour in social situations.
Test judgement: the following 2 problems are presented to the patient in a manner in which he can
comprehand.

9
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
1. Fire problem: If the house in which you are catches fire, what is the first thing you will do?
(Correct answer – try to pur it off with water)
2. Letter problem: If when you are walking on the roadside you see a stamped & sealed envelop
with an address on it which someone had dropped, what will you do? (correct answer – post it in a
letter box or give it the post man)
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 his illness and the cause of his
symptoms (Insight present)?

SUMMARY
The purpose of a summary is to provide concise description of all the important aspects of the case to
enable others who are unfamiliar with the patient to grasp the essential features of the problem the
summary should be presebted in the same format as described in the previous pages.
FORMULATION
This is the student’s own assessment of the case rather than as restatement of the facts. Its length
layout and emphasis will very considerably from one patient to another. It should always include a
discussion of the diagnosis, of the etiological factors which sees important, a plan of management
and an estimate of the prognosis, regardless the uncertainity or complexity of the case, a provisional
diagnosis should always be specified using the ICD. A complete physical examination is mandatory for
each patient.
INVESTIGATION TREATMENT AND FOLLOW-UP
Biochemical, radiological or psychometric investigations should be carried be out whenever
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.

EXAMINATION OF NON-CO-OPERATIVE OR STUPORPSE 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 stuper is during the stuporpse phase. 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
cover 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 awkward of uncomfortable positions
d) Behaviour toward physicians and nurses, resistive, evasive, irritable, apathetic, complaint.
e) Spontaneous acts: any occasional show of playfulness, mischievousness or assaultiveness.
Defence movements when interferred with or when prickle with pin-Eating and dressing. Attention to
10
 NIMHANS FORMAT OF HISTORY TAKING AND MENTAL STATE EXAMINATION – MAYER GROSS
bowels and blader. Do the movements show only initial retardation or are they consistent
throughout?
f) To what extent does the attitude change? Is the behaviour occurrances influence this
condition.

11