CASE RECORD

SOCIO DEMOGRAPHIC DETAILS:-

 Name:
 Age: Sex:
 Marital Status:
 Religion:
 Education:
 Occupation:
 Domicile:
 Address:
 Contact no.:
 Socioeconomic Status:
 Informant:
o Relationship with patient
o Intellectual and Observation ability,
o Familiarity with the patient and length of stay with patient
o Degree of concern regarding the patient
 Information: Reliability and adequacy
 Chief Complaints: (in chronological order)
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 Duration:
 Mode of Onset:
o Abrupt - Sudden appearance of signs and symptoms within 48 hours
o Acute -Rapid onset of signs and symptoms within more than 48 hours but less than 2 weeks
o Insidious - Onset of signs and symptoms takes more than 2 weeks or when the onset of illness
is subtle, and the symptoms develop so gradually that is difficult to ascertain when the onset
exactly occurred.
 Course of symptoms
 Episodic- An illness can be said episodic when it has an onset and an offset of signs and
symptoms of the disease with periods of recovery in between at least for a period of 2 months
 Fluctuating - When the course is waxing and waning especially under the effect of treatment.
e.g. Obsessive compulsive disorder, Schizophrenia
 Continues - Characterised by uninterrupted change without breaks or with steps infinitely
small and thus not detectable e.g. Schizophrenia.
 Progress:
o Improving- Improving from the date of onset e.g. Depression (with treatment)
o Deteriorating-Condition is getting worse by time e.g. Schizophrenia
o Static- Condition remains same no change happens e.g. Dysthymia

 Predisposing factors
o Factors operating from early life that determines a person’s vulnerability to develop a disorder
or likelihood that person will develop certain symptoms under given stress conditions.
o Biological (delayed milestones, head injury, family history of psychiatric illness)
o Psychological (impaired premorbid personality)
o Social (home atmosphere in childhood, neglect, abuse, low education level)
 Precipitating factors
o Events that occur shortly before the onset of a disorder and act as physical or psychosocial
stressors and lead to the onset of disorder in a person who may be predisposed to develop the
disorder
o Biological (fever, accident, onset of severe medical illness),
o Psychological (stress intolerance, poor impulse control),
o Social (trauma, loss of job/partner)
 Perpetuating factors- Factors due to which the disorder is maintained or aggravated.
o Biological (chronic medical illness, substance use)
o Psychological factors (poor insight, poor impulse control, low intelligence)
o Social (social isolation, unemployment, on-going expressed emotions in family)

 History of Present Illness:

o When the patient was last well
o Useful information about the onset as well as duration of illness
o Should be narrated chronologically, in coherent manner
o Should be expanded
o Any disturbances in physiological functions such as sleep, appetite and sexual functioning
should be enquired.
o Enquired about the presence of suicidal ideation, ideas of self harm and ideas of self harm to
other

 Negative History:

 Past Psychiatric and Medical History

o Any past history of having received any psychotropic medication and psychiatric
hospitalization should be enquired.
o Any serious medical or neurological illness, surgical procedure, accident or hospitalization
should be obtained.
o A past history of relevant aetiological causes such as head injury, convulsions,
unconsciousness, hypertension, HIV positivity etc. should be explored.

 Family History
o Family tree/ Genogram
o Current social situation
o Consanguinity between parents, living or dead family members, causes, age, education,
occupation, personality
o leader of the family
o Attitudes of family members towards the patient’s illness should be noted
o Family rituals, family burden
o Family psychiatric history, medical illness, alcohol or drug dependence and suicide (suicide
attempts)
 PERSONAL AND SOCIAL HISTORY:
 Birth and Developmental History:
 Prenatal – Any febrile illness, medications, drugs and alcohol use, abdominal trauma, any
physical or psychiatric illness should be asked.
 Perinatal – full term/ premature/ post mature, normal/ instrumental/caesarean.
 Post natal history: Any postnatal complications (cyanosis, convulsions, jaundice), Birth Cry
(immediate or delayed), any birth defects and any prematurity.
 Developmental milestones achieved on time or delayed
 Presence of childhood disorder:
 Presence of hyperactivity. Attention deficit, impulsivity, eating difficulties, enuresis, temper tantrums,
sleep disorder, lying, stealing, truancy (running away from school), bossy attitude towards younger
children, disturbed social relations with peers, not obeying rules while playing etc.
 Neurotic traits should be noted, these include stammering, tics, nail biting, head banging, body
rocking, morbid fear or phobias.

 Home Atmosphere in Childhood and Adolescence

 Disturbed/congenial/any abnormality of family situation viz. desertion by a parent, broken home,
step-parents, adopted sibs etc. and also patients attitude towards parents

 Scholastic and Extracurricular Activities:

o The age of beginning and finishing education
o Scholastic performance
o Attitude towards peers and teachers
o Discontinuity or change in school/college with reasons
o Involvement in games and extra-curricular activities.
o What games played at what stage, with whom and where.

 Occupational History:
o The age at starting work, Jobs held in chronological order, Duration at each work place, position held,
Reasons for changes, Job satisfactions, Ambitions, Relationship with work mates and superiors,
Present income, Job is appropriate to the educational and family background

 Menstrual History:
o Age of menarche should be asked.
o What was the reaction of patient towards it and also information and attitude towards mensuration
subsequently?
o Regularly and duration of usual cycle, whether associated with psychological and physical change
(pain or any other).
o Date of last menstruation, duration and reasons of amenorrhea, if any

 Sexual and Marital/Relationship History

o How and when sexual information and knowledge was first obtained and of what kind
o Masturbatory history (fantasy and activity), sex play if any
o Adolescent sexual activity, premarital and extramarital sexual relationship if any
o Sexual disorders (normal and abnormal),
o Presence of any gender identity disorder are areas to inquire about. Also probe for any history of
childhood sexual abuse.
o Marital history includes all enduring intimate relationships.
o Ask for age at marriage and parental consent for marriage.
o The spouse’s age, occupation, personality and state of health are relevant to the patient’s
circumstances should be documented.
o Also ask for role allocation, sharing of responsibilities and decision making, perceived adequacy of
sexual relation. Knowledge and use of contraception should be documented.
 Alcohol and Substance History:
o It can often contribute to causation of several psychiatric symptoms and are often present co-morbidly
alongside many psychiatric diagnoses.

 Forensic History:
o Trouble with police, law; charges and convictions (sections)
o Status of cases should be adequately mentioned here as per the available information.

 Premorbid Personality:
o Personality traits that existed before the development of a disease or disorder.
o Assess from patient/relatives/others who know the patient well. Mention source of information and its
reliability.
o 1. Social relations: How were his relation to family (attachment, dependence); to friends, groups,
societies, clubs; to work and work-mates (leader or follower, aggressive or submissive, organizer,
ambitious, adjustable, independent)?
o 2. Intellectual activities, hobbies and use of leisure time: Comment on books, plays, pictures
preferred; memory, observation, judgement, critical faculty
o 3. Predominant Mood: What used to be persistent mood like, was it cheerful or despondent; worrying
or placid; strung up or relaxed; optimistic or pessimistic; self-depreciative or satisfied? Was mood
changeable- could he express feelings of love, anger, frustration or sadness, did he loses control over
feelings, had he been violent? Was mood stable or unstable (with or without any reason)
o 4. Character:
 Attitude to Self
 Attitude to Work and Responsibility
 Interpersonal Relationship
 Standards in Moral, Religious and Health matters
 Energy, Initiative
o 5. Fantasy life
o 6. Habits