Pirogov vinnitsa national medical university

PIROGOV VINNITSA NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF PSYCHIATRY AND ADDICTOLOGY

CASE

HISTORY
Student_____________________________________

(surname, first name )

Faculty______________________________________
Year_______ Group___________________________

Vinnitsa 2013

I. Passport part:

Surname, name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

Date of birth _ _ _ _ _ _ _ Employment _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ Married /single/ divorced

Date of observation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date of hospitalization (newly-admitted, repeated) _ _ _ _ _ _ _ _

Diagnosis clinical preliminary _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Diagnosis final: а) cardinal _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

b) concomitant diseases _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

II. The patient's complaints: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
III. The patient's life history.

Heredity by mental diseases is negative /positive (undevelopment psychology, disease_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , epilepsy, suicidal, alcoholism, strange and specific character_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, vessel diseases.

Growth and developed in not/ acceptable/good socio-economic living conditions. Psycho-physical development of patient delayed /not delayed. School started in_ _ _ _year. Studied satisfactory /not /in mentally retarded school. Studied till_ _ _ _class. Qualification of secondary /specialization /higher ­­­­_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. Served in army /not.

VI. Treatment of given patient: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _­ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Doctor (Curator): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

vesicular / hard / diminished breath sounds _ _ _ _ _ _ _ _ _ _ _ _ . Rales not /dry /wet _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ in region _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. ­ Abdomen during palpitation soft /increased muscle tone /painful in region ­­­­­­­_ _ _ _ _ _ _ _ _ _ _ _ _ /not painful. Physiological excretion not impaired /constipation /loose motion/increased urination /complicated urination.

VI. Main psychopathological symptoms: comа, sopor, somnolence, faint; acute delusion, delirium, amnesia, oneiroid, twilight state; pathological affect, somnambulism (lunatic, ambulatory automatism, trans); hallucinosis, syndrome Kandinsky-Klerambo, syndrome derealisation or depersonalization, Korsakoff’s syndrome, amnestic syndrome, syndrome amentive speech confusion, delusion syndrome (paraphrenic, paranoid), maniac, melancholic, syndrome affective flattening, catatonic, hebephrenic; neurasthenic (hypersthenic, hyposthenic, labile, inert), hysteric, psychiasthenic, hypohondriac.

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VII. Laboratory investigation: Blood _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _RW _ _ _ _ _ _

Urine _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _; CSF _ _ _ _ _ _ _ _ _ ;

EEG_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ExoEG_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ECG_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _

Other paraclinical methods: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Work by specialization _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , year of experience­­­­­_ _ _ _ _ _ _ _ _ _ _ _

Child Disease: meseals, mums, diphtheria, parotidis, “influenza”, cranial trauma, dystrophy, avitaminosis, sleeptalking, nightmare, sleepwalking, enuresis, seizures, "stress", headache.

Got ill by: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ viral hepatitis, tuberculosis, syphilis, cranial trauma, operated yes /no.

Excess alcohol drinking, narcotic yes /no.

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

IV. Anamnesis morbi:

For present disease exogenic hazards were not / present (family lacking, conflicts at work difficulty in getting aims, non rational feeding, tiredness, sleeplessness, physical & mental stress, situations which needs will power to stay alive, unfairly victimized, afraid, emotional stress due to the hard time of relatives, unwilled presence in journey or presentation, infection, intoxication, different internal acute & chronic diseases, age changes).

Disease starts: date _ _ _ _ _ ­­­_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, gradual/acute.

Psychopathological symptoms: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Further disease movement (progradiently /attacks /periodic_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , attacks lasts for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _,
its psychopathological syndromes _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Time period & character of remises _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Ability to workin time of remises _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Other information _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Due to the impairment of psychological condition of patient, patient himself /in presence of relatives come to the psychiatric /through ambulance in OPD mental hospital and was hospitalized in _ _ _ _ _ ward.

V. Present condition of patient.

а) Psychological condition of patient: valuable contact is possible /low-/not. Conscious /un conscious: faintness, sopor, coma, oneirism, delirium, amnesia, twilight state. Auto- and allo-psychological orientation impaired /not /partly (in time, surrounding, individual).

Passive & active concentration not impaired /diffused, increased exhaustion, unidirectional movement, increased distractability, domination of passive concentration over active).

Disorders of sensation not found /anesthesia, hypo- /hyper- /paresthesis, sensopathy, hypohondric complains.

Disorders of perception not found /illusion /hallucination: taste /smell/ touch /visceral /general feeling /hear: true/pseudo hallucination, simple /complex: musical /verbal: imperative /comments / threatening; visional: macro- /microscopic, poliopic, adelomorphic, psychosensor violation: derealisation /depersonalization /dysmorphobia /metamorphosis /macro- & micropsy.

Disorders of memory not found /amnesia: fixed/total /lacunal /antero- /retrograde, progressive /stationary /regressive /retardation; hyper- /hypo- /paramnesia: confabulation /pseudoreminisation /cryptomnesia, amnestic Korsakoff’s syndrome: not /productive.

Mood leveled /decreased /depression / sad/increased /eforia /heboid; affective lability; irritation / hot temper / angry; affect physiological /pathological; fear motivated /no motivated, in day time not changed /increased in evening, obsessive: not /due to psycho emotional stress; emotional ambivalence /not adequate; parathymia.

Disorders of will power not found /hyperbulia /hypobulia /abulia; psychomotor excitation: catatonic /maniac /hallucination /isteric; stupor, sub stupor: flaccid /with hypertension of muscle: catalepsy /staircase symptom /air Dupre’s pillow /embryo position; amimia, mutism, negativism: active /passive; parabulia: mannerism,

bizarrerie motions, grimace; decreased /increased /change in instinct: self-defense, sexual, feeding.

Disorders of thinking not found /by temp: increased, decreased, galloping idea, mentism; by foundation: incoherent speech, not joined, verbigeration, perseveration, paralogic thinking, thought blocking; violation of amined thinking: circumstantiality of thinking, reasoning, symvolism, autistic thinking; pathologic of content of thought: overvalued ideas, obsessive thinking, delusions: monothematic /polythematic, systematic /non systematic, paranoic /paranoid /paraphrenic, delusions of persecution / grandiosity/ self-humiliation / damage.

Intellect meet with qualification & by life experience /oligophrenia / insufficient schooling /dementia: partly /total. Critic to his self condition total /decreased /absent.

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б) Neurological condition: Meningial symptom ­not /found. At the cranial nerves: iris D = /> /< S, iris reaction to light normal /slow /absent. Movement of eye ball saved /violated. Nistagm absent/horizontal /vertical/ finely sweeping / large sweeping. Trigeminal point painful /not painful. Face a /symmetric. Tongue at central line /displaced to right /left side. Paralysis, paresis absent /right- / left side mono-/para-/tetra paresis. Violation of senses absent /hyper-/hypo-/an-/paresthesis in region _______________________________. Skin, tendon, periosteal reflexes normal /slow/absent/ increased/ high, D = /> /< S. Pathological reflexes absent /present _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . Coordination of movement not /violated. In Romberg position steadiness /vacillation / unsteadiness. Demographism hard /soft red /white. Distal hypohydrosis present /not.

в) Somatic condition of patient: skeleton form normostenic / hyperstenic /astenic, satisfied /decreased /increased feeding. Weight_ _ _ _ _kg. Skin clean /present pimples /erytrhema /hematoma /ссадины /scars in region ­­­_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Pediculosis, itching not /found. Body temperature ­_ _ _ _^оС. Pulse _ _ _ /min. Blood pressure ­_ _ _ _ _ mm.Hg. Heart sound loud /low, accent I /II sound over aorta /pulmonary artery /not. Murmur systolic /diastolic at point _ _ _/not. Over lungs breathing is