Serial No.

Atbara teaching hospital

PSYCHIATRIC WARD

Name: ------------------------------

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Date of Admission:---------------- ------------------------- :

Consultant:-------------------------

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REGISTRATION FORM

Date of Registration:----------------------------------------------------------------Occupation:-----------------------------

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Address:

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sex :--------------------------------------

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Address: --------------------------------

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DIAGNOSIS :

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PSYCHIATRIST :--------------------

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REGISTRAR: -----------------------

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GENERAL PRACTIONER:--------

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RESULT :------------------------------

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Name-------------------------------------

Age:--------------------------------------

CASE HISTORY
Referred by:---------------------------------------------------------------------------Informant (Name, relation to patient):--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Complaint & Duration:-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------History of Present Illness :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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FAMILY HISTORY :
Father;
Mother:
Siblings ( in chronological order):

Home Atmosphere and social position:

PERSONAL HISTORY :
Pregnancy, birth and early development ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Neurotic Trait during Child hood:--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Health during Childhood:------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------School(Records, Career &Social Relationships):--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Occupation( current and previous)---------------------------------------------------------------------------------------------------------------------------------------------------------------------Psychosexual History including puberty ,menarche, sexual experiences, fantacies,
deviations and disorders:---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Marital History(spouse / children, harmony, separation, discords. Etc
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Past Medical History (head injury, convulsions ,accidents, coma etc
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Past Psychiatric History (start of illness, treatments, admissions etc)---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Personality Before Illness( Attitude towards self and others, aptitudes, coping
capacities interests ,habits ,hobbies.) ---------------------------------------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Alcohol ,Tobacco and drug abuse--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Social and other problems----------------------------------------------------------------------------------------------------------------------------------------------------Forensic History---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Examination:

Physical examination ( systemic general examination )-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------C.N.S (Higher brain functions, Reflexes, Sensations etc)---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Mental state examination :
Appearances & Behaviors(body built, dress, self care, general look,
cooperativeness and activity etc)----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Speech (rate, amount ,tone ,impairments)-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Mood (subjective, objective ,suicidal tendency and biological features)------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Though disorders( form : abstract/concrete, stream: fast/slow interrupted,content
:delusions ,overvalued ideas& obsession, Possession ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------------------------------------Disorders of perception (Hallucinations, illusions, depersonalization ,

derealization)----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Cognitive functions:
Orientation: TPP
Attention & concentration ---------------------------------------------------------: ( Days of the week backwards, monthsof year backwards , serials -7- test ,digit
span forwards & backwards ( 5 to 7 numbers)--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Memory (Immediate, Recent ,Remote) :
Immediate: name, address ,immediate recall, digit span--------------------------------------------------------------------------------------------------------------Recent :name, address , 5 minute recall ,recent meal etc---------------------------------------------------------------------------------------------------------------Remote: personal
events recalled from several years ago--------------------------------------------------------------------------------------------------------------Note &records; amnesia, par amnesias, confabulation and falsification. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Grasp &General information :(president& prime minister ,any item of current
affairs and hot issues on the news)----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Intelligence: (to be judged from history, educational and occupational records&
general knowledge) I.Q can be done later. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Judgment :how to tickle a problem ( given by the interviewer )------------------------------------------------------------------------------------------------------Insight : attitude towards illness ,whatever he think he is mentally ill and in
need of psychiatric treatment .--------------------------------------------------------------------------------------------------------------------------------------Formulation ( comprehensive account of the case , should include : a short
introduction of the case , salient features of the history and examination ,
important etiological factors ,evidence based diagnosis and differential diagnosis

,plan of short and long term management and prognosis )----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Working Diagnosis --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Follow-up ( including treatment and psychosocial findings)------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Follow up ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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-Psychological Assessment: evaluation , psychometry, psychotherapy & follow up

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Social Assessment:( evaluation, problems, plan of assistance if any & follow up --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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Name ---------------------------------------------------D.O.Birth-------------------Residence -----------------------------------------------Education -----------------Occupation ----------------------------------------------Marital status -----------D .O .A-------------------------------------------------- D.O.D. ---------------------Sources of referred-------------------------------------Treating unit ------------Presentation (includes F.H&P.H)------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Investigations (medical & psychiatric )---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Diagnosis---------------------------

-ICD code-----------

Management -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Recommendation ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Follow up --------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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