Scribd
Upload
34 views4 pages

History & MSE Checklist

The document is a comprehensive checklist for case history and mental status examination, detailing various aspects such as demographics, presenting complaints, nature of illness, treatment history, and mental status indicators. It includes sections on mood, thought processes, perception, cognitive functions, and judgment, providing a structured approach to assess a patient's mental health. The checklist aims to ensure thorough documentation and evaluation of the patient's condition.

Uploaded by

Ishita Rath
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
34 views4 pages

History & MSE Checklist

The document is a comprehensive checklist for case history and mental status examination, detailing various aspects such as demographics, presenting complaints, nature of illness, treatment history, and mental status indicators. It includes sections on mood, thought processes, perception, cognitive functions, and judgment, providing a structured approach to assess a patient's mental health. The checklist aims to ensure thorough documentation and evaluation of the patient's condition.

Uploaded by

Ishita Rath
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Case History Checklist

1. Demographics: Name; Age; Religion; Sex; Education; Occupation; Marital Status; SES;

Domicile.

2. Referral : Referred By ; Purpose of Referral

Note: Information given by the informant is adequate and reliable.

3. Presenting Complaints with onset Duration : Patient; Informant

4. Nature of Illness

- Onset : ▢ Abrupt ▢ Acute ▢ Insidious

- Course : ▢ Continuous ▢ Episodic ▢ Fluctuating


- Duration : ____________________________________

- Progress : ▢ Static ▢ Worsening ▢ Progressing


5. Influencing Factors: 4P

6. HOPI

7. Negative History

8. Treatment History of Current Illness:

- Treatment and Therapy history


- Compliance towards Medications

9. Past History: Past Psychiatric history; Past Medical History

10. Family History

11. Personal History: Birth & Development; Education; Occupation; Sexual & marital; Interpersonal

relations; Addiction, forensic.

- Addiction History: No. of substance; Types; Amount; Frequency; Peer/ company; Money

Spent; Route of use; effects of substance addiction.

12. Premorbid Personality: Mood; Character; Moral; Energy Initiative; Social Relations; Fantasy

Life; Hobbies; Habits.


Mental Status Examination Checklist

The pt was brought to hospital ▢ Restrained ▢ Unrestrained

The patient was in a state of ▢ Conscious ▢ Delirium ▢ Obtundation ▢ Stupor ▢ Coma

General Appearance and Behaviour

- Physical Appearance

Built : ▢ Ectomorph ▢ Mesomorph ▢ Endomorph


Hygiene:_______________________________________________________________

Grooming: ▢ Kempt ▢ Overly made up ▢ Unkempt ▢Sickly ▢ Perplexed

Dressing : ▢Appropriate ▢ Shabby ▢ inappropriate

- Touch with surrounding : ▢ Present ▢ Absent ▢Partial

- Eye contact: ▢ Maintained ▢ Partial ▢ Absent


- Facial expression : ____________________________________________________________
- Posture: ____________________________________________________________________

- Attitude towards examiner : ▢ Cooperative ▢ Attentive ▢ Defensive ▢ Hostile

▢ Seductive ▢ Guarded

- Rapport : ▢ Established ▢ Partial ▢ Difficult

Psychomotor activities: ▢ Retardation ▢ Hyperactive ▢ Preoccupied ▢ Mannerisms ▢ Grimace

▢ Awkward ▢ Silly smiling ▢ Tics ▢ Aggressive ▢ Odd posturing ▢ Waxy flexibility

▢ Echolalia ▢ Echopraxia ▢ Negativism ▢ Dystonia ▢ Dyskinesia ▢ Chorea ▢ Athetosis


Speech

- Intensity: ▢ High intensity ▢ Low intensity


- Pitch : ▢ Monotonous ▢ High ▢ Low
- Reaction time : ▢ Increased ▢ Decreased
- Speed : ▢ Very low ▢ Rapid ▢ Pressured speech
- Ease of speech : ▢ Mutism ▢Slurring ▢ Stuttering ▢ Whispering ▢ Muttering
- Relevant : ▢ Relevant ▢ Irrelevant
- Coherence : ▢ Coherent ▢ Incoherent
- Goal directed: ▢ Yes ▢ No
- Deviation: ▢ Rhyming and punning ▢ Talking past the point ▢ Clang association

Mood & Affect

- Mood: ____________________________________________________________________

- Affect: ▢ Dysphoric ▢ Anxious ▢ Irritable ▢ Depressed ▢ Elevated ▢ Euphoric ▢ Elated


▢ Ecstatic ▢ Euthymic

- Intensity of Affect: ▢ Shallow ▢ Blunted ▢ Flat

- Mobility of Affect: ▢ Constricted ▢ Fixed ▢ Liable


- Range: ▢ Full ▢ Restricted

- Reactivity: ▢ Reactive ▢ Non-reactive


- Communicability: __________________________________________________________

- Appropriateness: ▢ Appropriate ▢ Paramimia ▢ Parathymia

- Diurnal Variation of Affect: ▢ Worse in Morning ▢ Worse in Evening ▢ Worse at Night

- Affect ▢ Congruent ▢ Incongruent with mood.

Thought

- Stream: ▢ Volubility ▢ Acceleration ▢ Flight of ideas ▢ Prolixity Retardation (bradyphrenia)

▢ Circumstantiality ▢ Tangentiality ▢ Perseveration ▢ Thought blocking

- Form: ▢ Formal thought disorder ▢ Loosening of association ▢ Derailment

▢ Neologism ▢ Over Inclusion


- Possession: ▢ Obsession ▢ Rumination ▢ Compulsion ▢ Thought insertion

▢ Thought withdrawal ▢ Thought broadcasting ▢ Thought echo

- Content: ▢ Delusion ▢ Worry ▢ Phobia ▢ Impulsivity ▢ Somatic symptoms

▢ Religious preoccupations ▢ Excessive daydreaming ▢ Antisocial urges

▢ Homicidal ideas ▢ Philosophical ideas ▢ Magical thinking ▢ Depressive

▢ Suicidal ideas ▢ Death wishes ▢ Inflated self esteem


Perception

- Changes in Sensory Distortions: ▢ Intensity ▢ Quality ▢ Spatial Form

- Sensory Deception: ▢ Hallucination ▢ Illusion


- Others: Depersonalization: ▢ Derealization ▢ Body Image Disturbance ▢ Paramnesia

Cognitive Functions

- Orientation: ▢ Time ▢ Place ▢ Person

- Attention: ▢ Intact ▢ Impaired

- Concentration: ▢ Intact ▢ Impaired

- Memory: ▢ Immediate ▢ Recent ▢ Remote


- Abstract Ability: ▢ Functional ▢ Concrete ▢ Over-Abstraction

- Intelligence: ▢ Comprehension ▢ General Information ▢ Vocabulary ▢ Calculation

Judgment

- Social Judgment: ▢ Intact ▢ Impaired


- Personal Judgment: ▢ Intact ▢ Impaired
- Test Judgment: ▢ Intact ▢ Impaired

Insight: ▢ Grade 1 ▢ Grade 2 ▢ Grade 3 ▢ Grade 4 ▢ Grade 5 ▢ Grade 6

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy