Patient clinical notes
Demographic data
Name
Age Sex Religion Residance
Education level Occupation
Marital status Children
Reason for referal Informant
Presenting Complain(s):..................................................................
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Histroy of present illness the story of the patient( Clarification and analysis of symptoms, precipitating and predisposing factors)
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Impact of illness
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Past Psychiatric history
1st episode ......................................................................................
Onset & age of onset ......................................................................
Duration ….......................................................................................
Symptoms and diagnosis ...................................................................
Treatment& side effects .....................................................................
2nd episode ........................................................................................
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3rd episode ......................................................................................... ..........................................................................................................
Others................................................................................................
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Past & present medical history
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Alcohol and substance use history
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Family Study
Family structure
Name, age, occupation, education level, marital status,health
Father.............................................................................................
Mother: ...........................................................................................
Siblings:
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Family dynamics
Realtionship between parents .............................................................
Interaction between parents and patient ...............................................
Interaction between the siblings and patient ..........................................................................................................
Family rules ...................................................................................
Communication ..............................................................................
Family history of psychiatric disorder:
1st degree relative 2nd degree 3rd degree
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Home circumstances:
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Socioeconomic status
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Familial medical problems ......................................................................................................
Serious family events
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Childhood abuse
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Personal history
Psycosocial developmental history
Pregnancy..................................................................................................
Birth..........................................................................................................
Health of mother during pregnancy ..................................................................................................... .......
Early development :
Feeding: .
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Weaning: .........................................................................................................
Vaccination: ......................................................................................................
Childhood disease: ……………….......................................................................................................
Development milestone: .........................................................................................................................
Neurotic traits: .......................................................................................................................
Schooling:
Age………................... Type of school......................................................
Academic performance .....................................................................................................................
Social adaptation
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Discipline ......................................................................................................
Truancy and school refusal or schooll phobia
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Work records:
Nature of job: ......................................................................................................
Performance and punctuality: ...........................................................................................................................
Stability:
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Relationship with colleagues ........................................................................................................................
Financial income
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Previous jobs ..............................................................................................................
Psychosexual development:
Onset of Puberty ...................................................................................................... …………………
Masturbation......................................................................................................
Sexual experiences
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Sexual orientation
........................................................................................................................... nterpersonal issues ............................................................................................................................
Marital history:
Age at marriage
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Quality of marriage
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Sexual life
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Childern : Name Age Occupation
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Relationship between parents and childern
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Other issues.....................................................................................................................................................................................................
Pre – morbid personality :
Mood
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Sociability
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Adaptability
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Hobbies
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Habits
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Temper
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Motivation & productivity
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Physical Examination
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Mental State Examination
Appearance and behaviour...................................................................
Hygeine& dress ....................................................................................
Facial expression..................................................................................
Abnormal apperance .............................................................................
Motility Behaviour and body language
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Affect ...................................................................................................
Eye contact ..........................................................................................
Rapport................................................................................................
Catatonic features...................................................................................
Speech: amount. Volume. Relevant, any other abnormalities
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Mood examination
Subjective objective
Interest& feeling of pleasure .....................energy .................
Appetite ....................body weight .................. sleep....................
Libido .................................................................................................
Psychomotor behavior ....................................................................
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Somatic anxiety ..............................................................................
Examination of thinking
a) Shape ………..........................................................................................
b) stream .............................................................................................
c)contents :
Preoccupations .......................................................................................
Obsessional features ..............................................................................
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Overvalued ideas
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Delusions
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d) Possession ...................................................................................
Perception:
Sensory problems:
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Illusions
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Hallucinations
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Cognitive Assessment :
1.conciounsness
2.Orientation :
Time : Day Date Month Year
Passage of time ......................................................................................
Place ....................................................................................................
Persons ................................................................................................
3.Attention and concentration :
Serial7test.................................................................................................
Digit span …...............................................................................................
Spelling word .............................................................................................
Calculations ...............................................................................................
Days of the week/ months of the year .........................................................
3.Memory :
Immediate memory ...................................................................................
Recent memory .........................................................................................
Remote memory........................................................................................
Other memory problems.............................................................................
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4.Intelligence.......................................................................................
Judgment .............................................................................................
Insight.................................................................................................
Formulation
Demographic data :
Descriptive fomulation ( chiefly / derived form HPI&MSE)
nature of onset ,duration , the course , the main psychopathological feature
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Differential Diagnosis :
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Aetiology ( FH ,PH, Medical , Acohol & substences use )
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Investigations ( Medical & Psychological)
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Prognostic Factors :
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Plan of management
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دراسة الحالة باللغة العربية والانجليزية بصيغة pdfالأربعاء أكتوبر 17, 2012 11:53 am