ALL INDIA INSTITUTE OF MEDICAL SCIENCES

Mangalagiri, Andhra Pradesh – 522503

DEPARTMENT OF PSYCHIATRY
CASE PROFORMA

SOCIO-DEMOGRAPHIC DETAILS
Name: Age: Sex:
Marital status: Education: Occupation:
Religion: Family: Socio-economic status:
Address: Distance (approx. hrs taken):
Having a good understanding of these variables can at times influence the treatment decisions.
For example, which psychotropics to prescribe to a poor patient, which medications must not
be prescribed to a young women/elderly, how frequently can the patient be called for follow up.

INFORMANTS

 Relationship with the patient and whether staying with the patient since onset of illness.
 Reliability- Whether information is consistent amongst different informants and over
different periods of time.
 Adequacy- if with available information, a differential diagnosis can be made.

CHIEF COMPLAINTS
The main complaints in patient’s language in brief with their duration in chronological order.
It should be separately listed for both patients and caregivers.

HISTORY OF PRESENTING ILLNESS

1) TOTAL DURATION OF ILLNESS:

2) ONSET: The time period between the appearance of first symptom to full blown abnormal
symptoms/syndrome of a diagnosable disorder.
 Abrupt- 48hrs; Acute- 2 weeks; Insidious- months to years
3) COURSE: Description of the progression of the disorder.
 Continuous- fluctuating, stable, progressive, periodic exacerbation;
 Episodic- with complete or incomplete inter episodic recovery
4) PREDISPOSING, PRECIPITATING FACTOR, PERPETUATING FACTOR:
 Predisposing factors- Those risk factors which act for a longer period of time or
during an earlier part of life, makes an individual vulnerable to develop an illness.
 Precipitating factor- Those risk factors which operate immediately before the onset
of illness (i.e. have temporal co-relation with the onset of illness)
 Perpetuating/maintaining factor- which maintain or aggravate the illness.
a. How the symptoms began, and how they changed with time (gradual
progression/episodic/remained the same): Exact chronology of events/time frame
b. Evolution and course of symptoms, relationship of symptoms with each other, with life
changes and personality, with help-seeking and treatment.
c. Changes in the biological functions (sleep/appetite/weight), interpersonal relationships,
behaviors, personal habits, physical health and extent of socio-occupational dysfunction.
d. Association between symptoms and any stressors/life events- include situations at home,
work, school, legal issues, medical comorbidities, and interpersonal difficulties.
e. How was the predominant mood/ affect along with extensive elaboration of
phenomenology of psychotic/mood symptoms.
f. Effect of the symptoms on patient’s relationships, day to day activities and
work/occupation, social functioning etc.
g. Factors that alleviate or exacerbate symptoms (medications, support, coping skills, time)
h. All the symptoms and their severity with duration along with associated factors
i. All associated signs or symptoms must be explored to confirm syndromic presentation
j. Specific enquiry of suicidality and detail elaboration of any self-harm attempt
k. Co-morbid physical illness and substance abuse history in brief and any relationship of the
psychiatric history with the same should try to be explored.
l. Treatment received so far from all sources (medical and non-medical) with degree of
improvement and side-effects. It is also important to identify why the patient is seeking help
now. If any treatment has been received for the current episode, it should be defined in terms
of what was done (e.g., psychotherapy or medication), adequacy of the treatment and the
effect of these interventions.

PAST HISTORY
a. Co-morbid medical/surgical illness as well as treatments, both past and present.

Medical illnesses can precipitate a psychiatric disorder (e.g., depression in an individual

recently diagnosed with HIV), imitate a psychiatric disorder (hyperthyroidism
resembling an anxiety disorder), be precipitated by a psychiatric disorder or its treatment
(metabolic syndrome in a patient on a second-generation antipsychotic), or influence
choice of treatment (hepatic dysfunction disorder and the use of disulfiram).

b. Psychiatric history: All other psychiatric comorbidities, their course over the patient's
lifetime, including symptoms and treatment, prior episodes of same illness.
i. Description of past symptoms should include when they occurred, duration,
frequency and severity of episodes, along with treatment received
ii. Past treatment: medications (duration, doses, response, side-effects, compliance
& reason for discontinuation), ECT, hospitalization
iii. Specific enquiry into completeness of recovery and socialization/personal care
in the interim period.
iv. Past suicidal ideation, intent, plan, lethality of attempts; violence and homicidal
behavior; non-suicidal self-injurious behavior
FAMILY HISTORY

 Use of three generation pedigree chart/genogram with proper symbols is a must.

 Description of individual family members residing with patient (parents and siblings).
 Family income & socio-economic condition
 Family history of mental illness: including mental retardation, epilepsy, alcohol and/or
drug dependence, suicide, renouncing world etc.
 Family Dynamics- Roles of caregiver, decision-maker, earning members and relations.
 Attitude of the family towards the psychiatric illness-

PERSONAL HISTORY

1. Birth and early development

a. Antenatal and birth history- full term, hospital delivery, immediate cry after birth,
birth weight, any complications during delivery or post natal period
b. Early developmental history- developmental milestones

2. Childhood history-
a. General health in childhood
b. Neurotic traits- thumb-sucking, nail-biting, temper tantrums, bed-wetting,
stammering, tics
c. Childhood psychiatric illnesses
d. Childhood physical and sexual abuse, bullying

3. Education history- Highest level of educational attainment, behavioral problems at

school, academic performance, extracurricular activities and peer relationships

4. Occupation history- Jobs held in chronological order, give dates, adjustment with peers
and superiors, reasons for change of job.

5. Sexual & Marital History-

a. Age at menarche and menopause, menstrual cycles.
b. Marriage how arranged, duration, age and occupation of the spouse, general
adjustment, ages and gender of children.
c. Sexual adjustment, sexual problems in past and currently sexually active or not
d. Sexual preferences, gender identity, relationships as well as issues of intimacy

6. Substance use history- Duration, frequency and amount of use

PREMORBID PERSONALITY
Social relations, intellectual activities and hobbies, mood, character, attitude towards work and
responsibility, interpersonal relationships, energy, habits and fantasy life.
 PHYSICAL EXAMINATION
General:
 Appearance, body build and nutrition
 Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema
 Any evidence of thyroid swelling
 Any signs of injuries/hesitation cuts
Vitals:
Pulse: B.P.:
Ht: Wt: Waist circumference:
CVS: (Heart sounds)
Chest: (Breath sound, any adventitious sounds)
Abdomen: (Tenderness, mass, any rigidity)
CNS: Cranial nerve Examination :
Cranial Nerve Findings Cranial Nerve Findings
I VII
II VIII
III IX
IV X
V XI
VI XII
Motor system
Bulk UL LL
Tone UL LL
Power UL LL
Tendon reflexes Superficial Deep
Abdominal - Knee reflex-
Plantar – Flexor/Extensor Biceps reflex-
Triceps reflex-
Supinator reflex-
Sensory system
Fine touch UL LL
Vibration UL LL
Pain/Pressure UL LL
Proprioception UL LL
Stereognosis
Cerebellar signs:
 Gait (shuffling/waddling/scissoring/ swinging) –Describe
 Romberg’s Test –
 Dysdiadochokinesis –
 Finger-to-nose test –
 Heel-to-shin test –
Any meningeal signs of irritation –Kernig's sign, Brudzinski's sign
Skull and Spine -
 MENTAL STATE EXAMINATION (MSE)

1. GENERAL APPEARANCE, ATTITUDE AND BEHAVIOR (GAAB)

 General health and Body built: Lean/obese
 Dressing, grooming and kemptness
 Facial expressions, any abnormal movements or hallucinatory behaviour
 Eye to eye contact- Initiated/maintained
 Gait and posture
 Attitude: Cooperation/guardedness/evasiveness/hostility/apathetic/confused
 Rapport: The harmonious responsiveness of the physician to the patient and the patient
to the physician. It might be established with the patient easily, with difficulty, with
efforts or not established at all.
Example:
Patient entered the room alone, carried a water bottle in her hands, sat on chair offered and
returned greetings of the therapist; looked back to check if the door was closed. Was tidy and
well kempt. Appeared to be anxious in the beginning of the interview and had to be persuaded
several times to speak about her problems. Asked for reassurance 2- 3 times that if she can
get well soon. Kept on shifting her posture on chair; was fidgety and drank sips of water 2-3
times in between the interview. Eye to eye contact was initiated and maintained. Rapport
could be established.
2. PSYCHOMOTOR ACTIVITY: Motor activity may be described as normal, decreased
(generalized slowing, bradykinesia), or increased (agitated, restless).

3. SPEECH:
 Relevance : answering precisely (Relevant /irrelevant)
 Coherence : understandability (Coherent/incoherent)
 Spontaneous (on his own) / in response to question
 Rate/Tempo – speed (>150 words/min – pressure of speech)
 Reaction time: time taken to respond (average/ prolonged / reduced)
 Amount – increased/decreased/average
 Volume – amount the patient speaks on a particular subject; loudness (soft
whispering to loud speech)
 Tone – loudness
 Rhythm/Tonal inflections

4. MOOD AND AFFECT:

Mood: subjective, longitudinal or sustained
Affect: objective, cross-sectional
 Quality: happiness/sadness/anxious/irritable/euthymic
 Range of affective responses: Full/Restricted/Blunted/Flat
 Reactivity (changes in emotions w.r.t. environmental stimuli): present/absent
  Congruity (w.r.t. thought processes)
 Appropriateness (w.r.t. situations)
 Lability: rapid and extreme changes in emotions

5. THOUGHT:
Flow/stream/tempo:
 Increased- Flight of ideas, prolixity
 Decreased- Retardation of thinking, thought blocking
Form:
 How the thoughts are formulated, organized, and expressed
 Formal thought disorder: loosening of association, tangentiality, circumstantiality,
neologisms, poverty of content of speech
Content:
 Delusions are false, fixed ideas that are held despite evidence to contrary and are not
shared by others from the same socio-cultural and educational background.
(single/multiple; type- persecution, reference, grandeur, love, infidelity, guilt,
nihilism, poverty, somatic, hypochondriacal; exact content; fleeting or fixed)
 Worries, preoccupations, ideas of worthlessness, guilt, hopelessness, suicidal ideas
(intent, plan, preparation, frequency, fleeting or fixed)
Possession:
 Obsessions (repeated, intrusive, uncontrollable, ego-dystonic)
 Thought alienation (insertion, withdrawal, broadcast)

6. PERCEPTION: Hallucinations:
 Auditory (most common), visual, olfactory, tactile, gustatory
 What the patient is experiencing, when it occurs, how often it occurs, and whether
it is distressing, how many voices were heard, in which part of the day, male or
female voices, how interpreted and whether these are second person or third person
hallucinations (i.e. whether the voices were addressing the patient or were discussing
between themselves); also enquire about command (imperative) hallucinations
(which give commands to the person), whether the hallucinations occurred during
wakefulness, or were they hypnogogic (occurring while going to sleep) and/or
hypnopompic (occurring while getting up from sleep) hallucinations.
 Example : “I hear voices of two persons1 talking with each other. These are female
voices1, of my aunt and neighbor2. These voices are as clear3 as I am listening to you
and audible from ear. I am able to hear the other surrounding sound as well at the
same time4. The voices come from outside5; from a distance of about 10-15 m5. I
hear these voices 4-5 times a day6 for around 10-15 min7 each time continuously8.
At times, I hear them at normal volume9 at other time they whisper. They keep
talking ill things10 about me. I feel sad and get angry11. I tried to go out and find
them but could not find them. I at times cover my ear with hand12. But still not much
relief. I have no control13 over these voices. These voices seem real14 to me. I think
that other person nearby should be able to hear them, but my family member denies15
 hearing any such voices” [(1-Number/ Gender, 2- Known/Unknown,3- Clarity,4-
Consciousness,5- Location/Distance,6- Frequency,7- Duration,8- Constancy,9-
Intensity,10-Content,11-Affect,12- Behavior/acting out,13- Control,14- Reality,15-
Experiences shared )]

7. COGNITIVE FUNCTIONS: Higher Mental Functions:

A. Consciousness: conscious/ confusion/somnolence/clouding/delirium/stupor/coma

Orientation:
1) Time (time of day, date, day, month, year, season, time spent in hospital)
2) Place (present location, building, floor, city, and country)
3) Person (whether he can identify people around him and their roles)
B. Attention & Concentration:
 Attention: Ability to attend to a specific stimulus without being distracted by
extraneous internal or environmental stimuli
 Digit span test- forward and backward- read digits at one per second
 Patient is given the following instruction: ‘I will be saying some letters, listen
to me carefully. When I finish saying them, you will have to repeat them in
the same order’. Also give an example, ‘If I say 3, 7; you repeat 3, 7’.

 Concentration: Sustained attention (concentration) is the ability to maintain

attention to a specific stimulus over an extended period.
 Serial Subtraction Test: 100-7 (time, mistakes)- 120 sec; 40-3 (time,
mistakes)- 60 sec; 20-1 (time, mistakes)- 15 sec
 Enumerate the names of the months (or days of the week) in reverse order.
C. Memory:
 Immediate: Registration and Recall: repeat three words (for example
“school, purple, honesty”) and recall after 5 minutes.
 Recent: day-to-day events like recent meals, visitors to the hospital.
 Remote Memory: recall of facts or events that occurred years previously
(e.g., name of school, birth dates, historic facts, year of marriage)
D. Intelligence:
 General fund of knowledge: current prime minister of India, capital of
India, how the tea is made [procedure], crops in winter, 5 rivers/states
 Calculations: Addition, Subtraction, Multiplication & Division
 Comprehension: narrating simple stories and asking patient to tell the moral
of the story
 E. Abstract thinking :
 Ability to shift back and forth between general concepts and specific examples.
 Proverb interpretation
 Similarity testing: table/chair; apple/orange; bus/car [Abstract answer- both are
means of transportation; Concrete answer (focusing on external features) - both
have 4 wheels, steering, seat for sitting].

8. JUDGEMENT:
 Ability to take sound/correct decisions and act effectively on them.
 Personal judgement: inquiries about the patient’s future plans
 Social judgement: behavior in social situations
 Test judgement: Building on fire, stamped envelope on the road

9. INSIGHT
 Understanding of whether they have an illness, whether this illness is physical or
psychological, awareness of all the symptoms, what is the cause of the illness and
whether they need treatment, what would be their role in treatment etc.
1. Complete denial of illness.
2. Slight awareness of being sick and needing help, but denying it at the same time.
3. Awareness of being sick, but it is attributed to external or physical factors or
something unknown in self.
4. Intellectual Insight: Awareness of being ill and that the symptoms are due to own
particular irrational feelings/thoughts; yet does not apply this knowledge to the
current/future experiences.
5. True Emotional Insight: Awareness leads to significant changes in future behavior

PROVISIONAL DIAGNOSIS: