Case Report, MSE
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A case report provides a detailed account of a patient's symptoms, diagnosis, treatment, and outcomes. It includes a case history with identifying data, chief complaint, history of present and past illness, mental status examination, diagnostic findings, prognosis, and treatment plan. The case history gathering involves a psychiatric evaluation and psychosocial assessment to understand the patient's symptoms and formulate an effective treatment plan. A comprehensive treatment plan is developed using a multidisciplinary approach to address the patient's needs.
Case Report, MSE
- 3. CASE REPORT • A case report is a type of anecdotal evidence. • In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. • It is a detailed description of client’s background. • Is broadly focused and helps in diagnosis and formulating a specific and effective treatment plan. • The structure is not intended to be a rigid plan.
- 4. Components of a Case Report • Psychiatric History • Mental Status Examination • Further Diagnostic Studies • Summary of Findings • Diagnosis • Prognosis • Psychodynamic Formulation • Treatment Plan
- 5. Psychiatric History • It is the patient's life story told to the psychiatrist in the patient's own words from his or her own point of view. • It includes information about the patient obtained from other sources, such as a parent or spouse. • Is essential to making a correct diagnosis and formulating a specific and effective treatment plan.
- 6. Outline of Psychiatric History I. Identifying data II. Chief complaint III.History of present illness IV. Past illnesses – Psychiatric – Medical – Alcohol and other substance history V.Family history VI. Personal history (anamnesis) – Prenatal and perinatal – Early childhood (Birth through age 3) – Middle childhood – Late childhood (puberty through adolescence) – Adulthood – Sexual history – Fantasies and dreams – Values
- 7. Identifying Data Provide a succinct demographic summary of the patient( Name, age, marital status, sex, occupation etc…). Chief complaint The chief complaint, in the patient's own words. History of present illness A comprehensive and chronological background and development of the symptoms or behavioral changes.
- 8. Past psychiatric and medical history 1) Emotional or mental disturbances 2) psychosomatic disorders 3) medical conditions 4) neurological disorders Family history Psychiatric illness, hospitalization, and treatment of the patient's immediate family members. Ethnic, national, and religious traditions. Patient's attitude toward them.
- 9. Personal history (anamnesis) History of the patient's life from infancy to the present. • Prenatal & Perinatal • Early childhood (Birth through age 3) • Middle childhood (ages 3 to 11) • Later childhood (pre puberty through adolescence)
- 10. Adulthood Adulthood –Occupational history –Marital and Relationship History –Social activity –Education History –Religion –Adult sexuality –Legal History –Military history –Fantasies and Dreams –Value systems
- 11. Mental Status Examination • The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person. • It includes both objective observations of the clinician and subjective descriptions given by the patient.
- 12. Outline of Mental Status Examination 1. General Description 2. Speech 3. Mood and affect 4. Perceptions 5. Thinking – Form – Content 6.Sensorium and Cognition –Alertness –Orientation (person, place, time) –Concentration –Memory (immediate, recent, long term) –Calculations –Fund of knowledge –Abstract reasoning
- 13. General Description •Appearance •Behavior and psychomotor activity • Social Manner and nonverbal behavior •Trait and Posture •Attitude Toward Examiner
- 14. –Speech: Rapid, slow, pressured, hesitant, emotional, monotonous, loud, whispered, slurred, mumbled, stuttering, echolalia, intensity, pitch, ease, spontaneity, productivity, manner, reaction time, vocabulary, prosody. –Rate & Quantity (Spontaneous) –Volume & tone –Flow & Rhythm
- 15. Mood and affect Mood & Affect • Mood : A pervasive and sustained emotion that colors the person's perception of the world. what does patient say he or she feels; depth, intensity, duration, and fluctuations of mood. • Affect :The outward expression of the patient's inner experiences. It is the patient's present emotional responsiveness. Affect may or may not be congruent with. •Appropriateness of Affect
- 16. Thinking • Stream and Form Continuity of thought process • Content of thinking: Any preoccupations, environmental problems; obsessions, compulsions, phobias, specific antisocial urges or impulses are recorded.
- 17. • Perception Is the process of being aware of sensory experiences and being able to recognize it by comparing it with previous experiences. Hallucination: Occurs in the absence of external stimulus. Illusion and misinterpretation: Distorted perception. Depersonalization & Derealization Somatic Passivity Phenomenon: Presence of strange sensation described by the patient as being impaired on the body.
- 18. Sensorium and Cognition •Alertness: Awareness of environment, attention span, clouding of consciousness, fluctuations in levels of awareness. •Orientation Whether the patient is well oriented to time, place, person. •Consciousness: The intensity of stimulation needed to arose a person. •Concentration
- 19. • Intelligence: Is the ability to think logically, act rationally and deal effectively. • Abstract thinking: Ability to assume various aspects of a situation simultaneously. • Memory –Remote –Recent past memory: Past few months –Recent memory: Past few days, what did patient do yesterday, the day before, have for breakfast, lunch, dinner –Immediate retention and recall
- 20. Insight: Degree of personal awareness and understanding of illness. Judgment Ability to access a situation correctly and act appropriately with that situation. •Social judgment •Test judgment
- 21. Further Diagnostic Studies –Physical examination –Neurological examination –Additional psychiatric diagnostic –Interviews with family members, friends, or neighbors by a social worker –Psychological, neurological, or laboratory tests as indicated
- 22. Summary of Findings • Summarize mental symptoms, medical and laboratory findings, and psychological and neurological test results, if available. • Details regarding medications. • If DSM labels were included, be sure you've provided enough detail in the body of the report to support the diagnostic criteria as described in DSM. • Any recommendations for treatment can also go here.
- 23. Diagnosis • Diagnostic classification is made according to DSM-IV-TR uses a multiaxial classification scheme consisting of five axis Axis I: Clinical syndromes (e.g., mood disorders, schizophrenia, generalized anxiety disorder) Axis II: Personality disorders, mental retardation, and defense mechanisms Axis III: Any general medical conditions (e.g., epilepsy, cardiovascular disease, endocrine disorders) Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning exhibited by the patient during the interview (e.g., social, occupational, and psychological functioning.)
- 24. Prognosis • Opinion about the probable future course, extent, and outcome of the disorder, good and bad prognostic factors; specific goals of therapy. • Eg: Mr. X requires cognitive behavioural therapy and with appropriate intervention there should be good recovery within some six to nine months from the commencement of such.
- 25. Psychodynamic Formulation • Causes of the patient's psychodynamic breakdown, it’s influences in the patient's life that contributed to present disorder. • Outline of the major defense mechanism used by the patient. • Defense Mechanism are the psychological strategies an individual, a group or even the entire nation uses to cope with the reality and to maintain self image intact.
- 26. • A healthy person may use many defense mechanism. It becomes pathological when it is used persistently and if it distorts the reality and put the individual at risk. • Denial & Distortion –Schezotypal PD • Overcompensation -Narcissistic Personality Disorder • Dependence -Dependent PD • Dissociation -APD • Projection -Paranoid PD • Undoing -OCD
- 27. Comprehensive Treatment Plan • Modalities of treatment recommended. • Role of medication, inpatient or outpatient treatment. • Frequency of sessions, probable duration of therapy. • Type of psychotherapy; individual, group, or family therapy. • Symptoms or problems to be treated.
- 28. • Comprehensive treatment planning requires a therapeutic team approach using the skills of psychologists, social workers, nurses, activity and occupational therapists, and a variety of other mental health professionals, with referral to self-help groups if needed. • If either the patient or family members are unwilling to accept the recommendations of treatment and if it may have serious consequences, the patient, parent, or guardian should sign a statement to the effect that the recommended treatment was refused.
- 29. Conclusion • A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. • Case reports may contain Case history, MSE, Diagnosis, Prognosis and a Treatment Plan. • It’s structure is not intended to be a rigid plan. • The preparation of which require a team approach and the assistance of professionals like Social Worker, Psychologist and Psychiatrist.
- 30. Keywords• Affect • Appearance • Attitude • case history • Chief complaints • Delusions • Family history • Fantasies and dreams • Hallucinations • History of present illness • History of past illness • Legal history • Identifying data • Insight • Illusions • Judgment • Memory • Motor activity • Mood • Orientation • Personal history • Sexual history • Speech • Social interaction • Thought processes • Thought content • Values
- 31. Reference • Kaplan, H.I.&Sadock,B.J(1994).Synopsis of psychiatry- behavioural sciences/clinical psychiatry.(10th edi.)NY:willams &wilkins. • Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford University Press. p. 202. ISBN 0-19-506251-5. CaseReport(2011 November) from Wikipedia .Accessed on 20/2 / 2012 at : http://psychology.wikia.com/wiki/Caseeport Defense Mechanism(2011 November) from Wikipedia .Accessed on 20/2 / 2012 at :http://en.wikipedia.org/wiki/DefenseMechanism