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.

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