MENTAL STATUS
STATE OF CONSCIOUSNESS: clear, dim, amentia, delirium, oneiroid, twilight.
ORIENTATION: in time, surrounding, one’s own personality.
APPEARANCE: constitutional features, posture, posture, clothing, neatness, grooming, condition of nails and hair. Facial expression.
ATTENTION: passive, active. Ability to concentrate, stability, absent-mindedness, exhaustion, distractibility, poor distribution, inertia, pathological concentration, perseveration.
BEHAVIOR AND MENTAL ACTIVITY: gait, expressiveness of movements, adequacy to experiences, gestures, mannerisms, tics, twitching, stereotypical movements, angularity or plasticity, agility of movements, lethargy, hyperactivity, agitation, belligerence, echopraxia.
SPEECH: (quantity, quality, speed) fast, slow, labored, stuttering, emotional, monotonous, loud, whispering, slurred, mumbling, with echolalia, speech intensity, pitch, ease, spontaneity, productivity, manner, reaction time, lexicon.
ATTITUDE TOWARDS THE CONVERSATION AND THE DOCTOR: friendly, attentive, interested, sincere, flirtatious, playful, inviting, polite, curious, hostile, defensive, reserved, wary, hostile, cold, negativistic, posturing. Degree of contact, attempts to avoid conversation. Active desire for conversation or passive submission. Presence or absence of interest. The desire to emphasize or hide a painful condition.
ANSWERS TO QUESTIONS: exhaustive, evasive, formal, deceitful, irritable, rude, cynical, mocking, brief, verbose, generalized, with examples.
EMOTIONAL SPHERE: prevailing mood (color, stability), mood fluctuations (reactive, autochthonous). Excitability of emotions. Depth, intensity, duration of emotions. Ability to regulate emotions, restraint. Melancholy, a feeling of hopelessness, anxiety, tearfulness, timidity, attentiveness, irritability, horror, anger, expansiveness, euphoria, a feeling of emptiness, guilt, inferiority, arrogance, agitation, dysphoria, apathy, ambivalence. Adequacy of emotional reactions. Suicidal thoughts.
THINKING: thoughts, judgments, conclusions, concepts, ideas. Tendency to generalizations, analysis, synthesis. Spontaneity and non-spontaneity in conversation. Pace of thinking, correctness, consistency, clarity, focus, switching from one topic to another. Ability to make judgments and inferences, relevance of answers. Judgments are clear, simple, adequate, logical, contradictory, frivolous, complacent, vague, superficial, stupid, absurd. Thinking abstract, concrete, figurative. Tendency to systematize, thoroughness, reasoning, pretentiousness. Contents of thoughts.
MEMORY: dysfunction of fixation, storage, reproduction. Memory for past life events, recent past, remembering and reproducing current events. Memory disorders (hyperamnesia, hypomnesia, amnesia, paramnesia).
INTELLECTUAL SPHERE: assessment of the general level of knowledge, educational and cultural level of knowledge, prevailing interests.
CRITICISM: the patient’s degree of awareness of his illness (absent, formal, incomplete, complete). Awareness of the connection between painful experiences and disorders of social adaptation with the underlying disease. The patient's opinion about changes since the onset of the disease. The patient's opinion about the reasons for admission to the hospital.
Mood and attitude towards the upcoming treatment. The patient’s place in the upcoming treatment process. Expected Result.
PSYCHOPATHOLOGICAL PRODUCTS (perceptual deceptions, delusions).
COMPLAINTS ON ADMISSION.
Determination of mental status is the most important part of the process of psychiatric diagnosis, that is, the process of knowing the patient, which, like any scientific cognitive process, should not occur chaotically, but systematically, according to a scheme - from phenomenon to essence. Actively purposeful and in a certain way organized living contemplation of a phenomenon, that is, the determination or qualification of the patient’s real status (syndrome) is the first stage in recognizing the disease. Poor quality research and description of the patient’s mental status most often occurs for the reason that the doctor has not mastered and does not adhere to a specific plan or scheme for studying the patient, and therefore does it chaotically.
Because the mental illness is the essence of a personality illness, then the mental status of a mentally ill person will consist of personal characteristics And psychopathological manifestations, which are conventionally divided into positive and negative. Adopting the conventions, we can say that the mental status of a mentally ill person consists of three “layers” of PNL: positive disorders (P), negative disorders (N) and personal characteristics (P).
In addition, manifestations mental activity can be conditionally divided into four main spheres of PEPS: 1. Cognitive (intellectual-mnestic) sphere, which includes perception, thinking, memory and attention (P). 2. Emotional sphere, in which higher and lower emotions (E) are distinguished. 3. Behavioral (motor-volitional) sphere, in which instinctive and volitional activity (P) are distinguished. 4. The sphere of consciousness, in which three types of orientation are distinguished: allopsychic, autopsychic and somatopsychic (C).
Table 1. Structural and logical diagram of mental status
|
Mental activity |
Positive disorders (P) |
Negative disorders (N) |
Personality characteristics (L) |
|
|
Cognitive sphere (P) |
Perception Thinking Attention |
|||
|
Emotional sphere (E) |
Lower emotions Higher emotions |
|||
|
Behavioral domain (P) |
Instinctive activity Volitional activity |
|||
|
Sphere of Consciousness (C) |
Allopsychic orientation Autopsychic orientation Somatopsychic orientation |
A description of the mental status is carried out after drawing up an idea of the syndrome that defines the condition, its structure and individual characteristics. The description of the status is descriptive, avoiding the use of psychiatric terms whenever possible, so that another physician reviewing the medical history will therefore clinical description I could, through synthesis, give this condition its own clinical interpretation and qualification. Adhering to the structural-logical scheme of mental status, it is necessary to describe four spheres of mental activity. You can choose any sequence when describing these spheres of mental activity, but you must follow the principle: without completely describing the pathology of one sphere, do not move on to describing another. With this approach, nothing will be missed, since the description is consistent and systematized.
It is recommended to begin the presentation of the mental status with a description of the patient’s appearance and behavior. It should be noted how the patient was brought to the office (he came alone, accompanied, went to the conversation willingly, passively, or refused to come into the office), the patient’s posture during the conversation (stands, sits quietly, moves carelessly or restlessly, jumps up, where- sometimes strives), his posture and gait, facial expression and eyes, facial expressions, movements, manners, gestures, neatness in clothing. Attitude to the conversation and the degree of interest in it (listens with concentration or is distracted, does he understand the content of the questions and what prevents the patient from understanding them correctly).
Features of the patient’s speech: shades of voice (modulation of timbre - monotonous, loud, sonorous, quiet, hoarse, shouting, etc.), rate of speech (fast, slow, with pauses or without stops), articulation (chanted, stuttering, lisp) , vocabulary (rich, poor), grammatical structure of speech (ungrammatical, broken, confused, neologisms), purposefulness of answers (adequate, logical, essentially or not essentially, specific, thorough, florid, one-dimensional, diverse, complete, torn and etc.).
The availability or lack of availability of the patient should be noted. If it is difficult to make contact, reflect what is causing this (active refusal of contact, impossibility of contact due to psychomotor restlessness, mutism, stunning, stupor, coma, etc.). If contact is possible, the patient’s attitude to the conversation is described. It is necessary to emphasize whether the patient actively or passively expresses his complaints, what emotional and vegetative coloring they are accompanied by. It should be indicated if the patient does not complain about his mental condition and denies any mental disorders. In these cases, actively questioning the patient, the interpretation given by him of the very fact of being admitted to the hospital is described.
The holistic behavior, the correspondence (inconsistency) of the patient’s actions with the nature of his experiences or the environment is described. A picture of unusual reactions to the environment, contacts with other patients, staff, acquaintances and relatives is given. general characteristics personality with an assessment of their condition, attitude towards loved ones, towards treatment, immediate and distant intentions.
Following this, it is necessary to describe the patient’s behavior in the department: his attitude towards eating, medications, staying in the hospital, attitude towards surrounding patients and staff, tendency to communicate or isolate himself. The description of the mental state ends with a presentation of the results of a study of attention, memory, thinking, intelligence and criticism of the patient in relation to the disease and the situation as a whole.
Borohov. HELL.
Herzog Hospital, Jerusalem, Israel
Overload of modern stationary psychiatric departments is one of the main problems requiring not only additional financial allocations, but also an increase in human resources.In a context of tight budgets and rate cuts medical personnel, the individual workload on each employee naturally increases. Moreover, we consider as an additional stress factor the increase in the frequency of nurses' shifts and doctors' shifts, with increased workload, since the usual occupancy of the department exceeds 100%.
Listed negative factors lead not only to a deterioration in the quality of work with patients, but also significantly affect the physical and emotional condition employees, which subsequently leads to the formation of the “burnout” syndrome.
Standardization of data in medicine, and in particular in psychiatry, not only reduces the amount of time spent searching for the necessary material, but also, when filling out a medical history, does not miss important facts and data that significantly affect the dynamics healing process. Moreover, it facilitates mutual understanding between the doctor and nursing staff, thereby making the treatment process more effective. It is nurses who are in first place in terms of the amount of “pure time” of contact with patients. Nursing staff are a necessary intermediate link between the doctor and the patient. Since it is not only the professional “eyes” and “ears” of the doctor, but also the “hands” (injection procedures, “non-drug fixation” aggressive patients). That's why experienced doctor, first of all, must explain and teach nursing staff and young colleagues the requirements that he considers necessary and conducive to the successful treatment of patients.
The goal of this work is to reduce time costs, improve mutual understanding between various levels of medical personnel, thereby making the work more professional, high-quality and efficient.
All this allows not only “everyone to move in the same direction at the same time,” but also makes employees a full-fledged team, the group goal of which is successful treatment patient. Such an approach not only improves the emotional microclimate in the team, thereby reducing stress, but also makes the therapeutic process professionally interesting.
Patient's psychiatric status
State of consciousness
1. clear
2. confused
3. stupor
4. comaAppearance
1. neat, dressed for the weather
2. untidyPersonal hygiene status
1. normal
2. reduced
3. launchedOrientation
1. time
2nd place
3. self and others
4. situation
5. fully orientedCooperation during the examination
1. complete
2. partial\formal
3. absentBehavior
1. calm
2. hostile
3. negative
4. aggressive arousal
5. apathetic
6.___________________Mood (patient self-esteem)
1. normal, usual
2. reduced
3. raised, very good
4. depressed, bad
5. alarming
6. tense, nervousPsychomotor activity
1. inhibited
2. constrained, rigid
3. tremor
4. waxy flexibility
5. threatening gestures
6. ___________________
7. normalAffect
1. angry
2. suspicious
3. anxious
4. depressed
5. maniform
6. labile (unstable)
7. scared
8. tapered
9. flat
10. euthymic (adequate)
11.__________________Speech
1. clean, correct
2. stuttering
3. slow
4. fast
5. slurring
6. complete mutism
7. selective mutism
8. mutenessDisorders of the thinking process
A. Yes B. No
1. accelerated
2. slow motion
3. circumstantial
4. tangential
5. weakness of associations
6. block\sperrung
7. perseveration
8. verb generation
9. echolalia
10. jumping from topic to topic
11. flight of thoughts
12. fragmented thoughts
13. verbal okroshka
14. ____________________Violation of the content of thinking
A. Yes B. No
1. relationship ideas
2. delusions of grandeur
3. fears
4. obsessions
5. delusion of persecution
6. delirium of jealousy
7. low self-esteem
8. Ideas of self-blame
9. thoughts about death
10. thoughts of suicide
11. thoughts of murder
12. thoughts of revenge
13. ___________________Perception disturbance
A. Yes B. No
1. illusions
2. visual hallucinations
3. auditory hallucinations
4. tactile hallucinations
5. taste hallucinations
6. depersonalization
7. derealization
8. ____________________Substance abuse
A. Yes B. No
1. alcohol __________________________________________
2. cannabis _____________________________________________
3. opiates _____________________________________________________
(experience of use, dose, frequency, method, last dose)
4. amphetamines ________________________________________
(experience of use, dose, frequency, method, last dose)
5. hallucinogens _____________________________________
(experience of use, dose, frequency, method, last dose)
6. benzodiazepines _____________________________________
(length of use, dose, frequency, last dose)
7. barbiturates _____________________________________________________
(length of use, dose, frequency, last dose)
8. cocaine / crack ________________________________________
(experience of use, dose, frequency, method, last dose)
9. ecstasy ________________________________________________
(length of use, dose, frequency, last dose)
10. phenylcyclidine (PCP) ___________________________________
(length of use, dose, frequency, last dose)
11. inhalants, toxic substances ________________________
(length of use, dose, frequency, last dose)
12. caffeine ________________________________________________
(experience of use, dose, frequency, method, last dose)
13. nicotine ________________________________________________
(length of use, dose, frequency, last dose)
14. _______________________________________________________
(length of use, dose, frequency, last dose)Impaired concentration and attention
1. no
2. mild
3. significantMemory impairment
A. Yes B. No
1. immediate memory
2. short-term memory
3. long-termIntelligence
1. Appropriate to age and education received
2. Does not correspond to age and education received
3. It is not possible to evaluate due to the patient's conditionAwareness of the presence of the disease
A. Yes B. NoUnderstanding the need for treatment
A. Yes B. NoAssessment of suicidal activity
Suicide attempts and past self-harm
________________________________________________________________
(quantity, year, reason)
Methods of committing suicide
_________________________________________________________________
Having a desire to commit suicide _______
(patient rating of desire strength: from 0 (minimum) to 10 (maximum))Brief somatoneurological status of the patient
Constitutional body structure
1. asthenic
2. normosthenic
3. hypersthenicPower Status
1. normal
2. reduced
3. cachexia (exhaustion)
4. overweightFood allergy
A. Yes B. No
1.________________________
2.________________________
3.________________________
4. ________________________
5. ________________________
6. ________________________Drug allergy
A. Yes B. No
1.________________________
2.________________________
3.________________________
4. ________________________
5. ________________________
6. ________________________Presence of concomitant diseases
A. Yes B. No
1.________________________
2.________________________
3.________________________
4. ________________________
5. ________________________
6. ________________________Availability hereditary diseases and degree of relationship
A. Yes B. No
1.________________________
2.________________________
3.________________________
4. _______________________Presence of orthopedic problems
A. Yes B. No
1. Moves independently with the help of a stick/crutches
2. Needs assistance or support from staff
3. Cannot move even with assistanceHaving problems controlling the sphincters
A. Yes B. No
1. urinary incontinence
2. nocturnal enuresis
3. fecal incontinenceExternal indicators
1. pressure ______________
2. pulse__________
3. temperature______________
4. blood sugar level ____________Skin condition
1. clean, natural color
2. pale
3. cyanotic
4. hyperemic __________________
WhereThe presence of exogenous and endogenous changes in the skin
A. Yes B. No
1. scar/scar__________________
Where
2. traces of injections __________________
Where
3. wounds __________________
Where
4. bruises __________________
Where
5. tattoos __________________
Where
6. piercing __________________
WhereSclera of the eyes
1. regular color
2. icteric
3. hyperemic “injected”Pupils
1. Symmetrical
2. Anisocoria
3. Miosis
4. MydriasisIn accordance with the actual operating conditions of a particular department, the scope of psychiatric status can be modified, the main thing is that it remains standardized.
Our recommendations are based on more than twenty-five years clinical experience working with patients, as well as teaching clinical psychiatry to students medical colleges and universities, both in the territory former USSR, and in Israel.
A detailed study of the status in practice does not take more than forty-five minutes; with certain experience, the time is reduced to half an hour.
It is important to note that standardizing the status upon admission to the hospital allows you to methodically examine the patient, avoiding not only wasting time, but also annoying omissions and errors that inevitably arise when the volume of work increases. In addition, the recommended psychiatric status allows you to consider the patient's condition over time and focus on specific symptoms and syndromes
In conclusion, I would like to remind you that the psychiatric status is somewhat reminiscent of board game"Lego", i.e. a picture that we assemble from many details. Moreover, each fragment has its own specific place in this picture, even without just one or two fragments clinical picture will not look full, which may accordingly affect the duration and effectiveness of the treatment process.
We're all kind of a little crazy. Has this thought ever occurred to you? Sometimes it seems to a person that his mental status is clearly beyond the limits of what is permissible. But, so as not to think and guess in vain, let's look at the nature of this condition and find out what an assessment of mental status is.
Description of mental status
It should be noted that before, so to speak, delivering his verdict, the specialist studies the mental state of his client through a conversation with him. He then analyzes the information he receives as his responses. The most interesting thing is that the “session” does not end there. The psychiatrist also evaluates the person’s appearance, his verbal and non-verbal (that is, behavior, speech).
The doctor’s main goal is to find out the nature of the appearance of certain symptoms, which can be either temporary or progressing to the stage of pathology (alas, the latter option is less joyful than the first).
We will not delve into the process itself, but we will give some recommendations as an example:
- Appearance. To determine mental status, pay attention to appearance person, try to determine what social environment he belongs to. Make a picture of his habits and life values.
- Behavior. This concept should include the following: facial expression, movements, facial expressions, gestures. The latter criteria help to better determine the mental status of the child. After all, his nonverbal body language is more pronounced than that of an adult. And this suggests that, if something happens, he will not be able to evade answering the question posed.
- Speech. Pay attention to speech features of a person: the pace of his speech, monosyllabic answers, verbosity, etc.
Passport part.
FULL NAME:
Gender: male
Date of birth and age: September 15, 1958 (45 years old).
Address: registered in TOKPB
Cousin's address:
marital status: Not maried
Education: secondary vocational (surveyor)
Place of work: not working, disabled group II.
Date of admission to hospital: 10/6/2002
Diagnosis of direction according to the ICD: Paranoid schizophrenia F20.0
Final diagnosis: Paranoid schizophrenia, paroxysmal type of course, with an increasing personality defect. ICD-10 code F20.024
Reason for admission.
The patient was admitted to the Tomsk Regional Clinical Hospital on October 6, 2002 by ambulance. The patient’s cousin asked for help due to his inappropriate behavior, which consisted in the fact that during the week before admission he was aggressive, drank a lot, had conflicts with relatives, suspected them of wanting to evict him and deprive him of his apartment. The patient’s sister invited him to visit, diverted his attention, interested him in children’s photographs, and called an ambulance.
Complaints:
1) on bad dream: falls asleep well after taking aminazine, but constantly wakes up in the middle of the night and cannot fall asleep again, time of onset of this disorder does not remember;
2) on headache, weakness, weakness, which connects both with the reception medicines, and with an increase blood pressure(maximum numbers - 210/140 mmHg);
3) forgets first and last names.
4) cannot watch TV for a long time - “the eyes get tired”;
5) it’s hard to work “tilt”, you feel dizzy;
6) “cannot do the same thing”;
History of present disorder.
From the words of relatives, we managed to find out (by telephone) that the patient’s condition changed 1 month before hospitalization: he became irritable and actively engaged in “entrepreneurial activities.” He got a job as a janitor in a cooperative and collected 30 rubles from residents. per month, worked as a loader in a store, and repeatedly took food home. He didn’t sleep at night, when his relatives asked him to see a doctor, he became irritated and left home. Ambulance was called by the patient’s cousin, because during the week before admission he became fussy, drank a lot, began to conflict with relatives, accusing them of wanting to evict him from the apartment. Upon admission to the TOKPB, he expressed certain ideas about his attitude, could not explain the reason for his hospitalization, stated that he agreed to stay in the hospital for several days, and was interested in the duration of the hospitalization, since he wanted to continue working (he did not collect money from everyone). Attention is extremely unstable, speech pressure, speech is accelerated in tempo.
Psychiatric history.
In 1978, while working as the head of a geodetic party, he experienced a pronounced feeling of guilt, reaching suicidal thoughts due to the fact that his wage was higher than that of his colleagues, while the responsibilities were less burdensome (in his opinion). However, it didn’t come to the point of suicide attempts - love and affection for her grandmother stopped her.
The patient considers himself sick since 1984, when he first came to psychiatric hospital. This happened in the city of Novokuznetsk, where the patient came “to work.” He ran out of money and wanted to sell his black leather bag to buy a ticket home, but no one bought it at the market. Walking down the street, he had the feeling that he was being followed; he “saw” three men who were “following him and wanted to take his bag.” Frightened, the patient ran to the police station and pressed the button to call a policeman. The police sergeant who appeared did not notice the surveillance, told the patient to calm down and returned to the department. After the fourth call to the police, the patient was taken to the police station and “began to be beaten.” This was the impetus for the onset of an affective attack - the patient began to fight and scream.
A psychiatric team was called and the patient was taken to the hospital. On the way, he also fought with the orderlies. He spent six months in a psychiatric hospital in Novokuznetsk, after which he “on his own” (according to the patient) went to Tomsk. At the station, the patient was met by an ambulance team, which took him to the regional psychiatric hospital, where he stayed for another year. Of the drugs used for treatment, the patient remembers only chlorpromazine.
According to the patient, after the death of his grandmother in 1985, he went to the city of Biryusinsk, Irkutsk region, to live there my own sister. However, during one of the quarrels with his sister, something happened (the patient refused to specify), which led to the sister’s miscarriage and the patient’s hospitalization in a psychiatric hospital in Biryusinsk, where he stayed for 1.5 years. It is difficult to indicate the treatment being carried out.
It should be noted that, according to the patient, he “drank a lot, sometimes it was too much.”
The next hospitalizations were in 1993. According to the patient, during one of the conflicts with his uncle, in a fit of anger he told him: “Or you can hit him in the head with an ax!” My uncle was very scared and therefore “deprived me of my registration.” Afterwards, the patient very much regretted the words he had spoken and repented. The patient believes that it was the conflict with his uncle that was the reason for his hospitalization. In October 2002 - real hospitalization.
Somatic anamnesis.
He doesn’t remember any childhood illnesses. Notes a decrease in visual acuity from class 8 to (–) 2.5 diopters, which persists to the present day. At the age of 21 he suffered open form pulmonary tuberculosis, was treated at a tuberculosis dispensary, does not remember medications. For the last five to six years, he has been experiencing periodic rises in blood pressure to a maximum of 210/140 mm. Hg Art., accompanied by headache, tinnitus, flashing of flies. He considers blood pressure figures to be 150/80 mm as normal. Hg Art.
In November 2002, while in the Tomsk Regional Clinical Hospital, he suffered from acute right-sided pneumonia and was treated with antibiotics.
Family history.
Mother.
The patient does not remember the mother well, since she spent most of her time as an inpatient in a regional psychiatric hospital (according to the patient, she suffered from schizophrenia). She died in 1969, when the patient was 10 years old; the mother does not know the cause of death. His mother loved him, but could not significantly influence his upbringing - the patient was raised by his maternal grandmother.
Father.
The parents divorced when the patient was three years old. After this, my father left for Abkhazia, where he started a new family. The patient met his father only once in 1971 at the age of 13, after the meeting he was left with painful, unpleasant experiences.
Siblings.
The family has three children: elder sister and two brothers.
Older sister is a teacher primary school, lives and works in the city of Biryusinsk, Irkutsk region. Mental illness doesn't suffer. The relationship between them was good and friendly; the patient says that he recently received a postcard from his sister and showed it to him.
The patient’s middle brother has been suffering from schizophrenia since the age of 12, is a group II disabled person, is constantly being treated in a psychiatric hospital, and currently the patient knows nothing about his brother. Before the onset of the disease, my relationship with my brother was friendly.
The patient's cousin is also currently being admitted to the TCU for schizophrenia.
Other relatives.
The patient was raised by his grandparents and older sister. He has the most tender feelings for them, and speaks with regret about the death of his grandfather and grandmother (his grandfather died in 1969, his grandmother in 1985). However, the choice of profession was influenced by the patient’s uncle, who worked as a surveyor and topographer.
Personal history.
The patient was a wanted child in the family; there is no information about the perinatal period and early childhood. Before entering the technical school, he lived in the village of Chegara, Parabelsky district, Tomsk region. Among his friends he remembers “Kolka”, with whom he still tries to maintain a relationship. Preferred games in company, smoked from the age of 5. I went to school on time, loved mathematics, physics, geometry, chemistry, and received “C” and “D” in other subjects. After school, I “went to drink vodka” with friends, and the next morning I was “sick with a hangover.” He showed a desire for leadership in the company and was the “ringleader.” During fights, I experienced physical fear of pain. The grandmother did not raise her grandson very strictly; she did not use physical punishment. The role model was the patient's uncle, a surveyor-topographer, who subsequently influenced the choice of profession. After finishing 10th grade (1975), he entered the geodesy technical school. I studied well at the technical school, future profession I loved.
I tried to be in a team, I tried to support people a good relationship, however, he had difficulty controlling his feelings of anger. I tried to trust people. “I trust a person up to three times: once he deceives me, I will forgive, the second time he deceives me, I will forgive, the third time he deceives me, I will already think what kind of person he is.” The patient was absorbed in work, the prevailing mood was good and optimistic. There were difficulties in communicating with girls, but the patient does not talk about the reasons for these difficulties.
I started working at the age of 20 in my specialty, I liked the work, there were good relationships with the work team, and I held small management positions. He did not serve in the army due to pulmonary tuberculosis. After his first hospitalization in a psychiatric hospital in 1984, he changed his job many times: he worked as a salesman in a bread store, as a janitor, and washed entrances.
Personal life.
He was not married, at first (until the age of 26) he thought “it was too early,” and after 1984 he did not marry for the reason (according to the patient) “what’s the point of producing fools?” He did not have a permanent sexual partner; he had a wary attitude towards the topic of sex and refused to discuss it.
Attitude to religion.
He showed no interest in religion. However, in Lately began to recognize the presence of a “higher power,” God. Considers himself a Christian.
Social life.
He has not committed any criminal acts and has not been brought to trial. Didn't use drugs. He has been smoking since he was 5 years old, then - 1 pack a day, recently - less. Before hospitalization, he actively consumed alcohol. He lived in a two-room apartment with his niece, her husband and child. He loved to play with the child, look after him, and maintained a good relationship with his niece. He had conflicts with his sisters. The last stress was a quarrel with my cousin and uncle before hospitalization about the apartment, which I am still experiencing. No one visits the patient in the hospital; relatives ask doctors not to give him the opportunity to call home.
Objective history.
It is impossible to confirm the information received from the patient due to the lack of outpatient card patient, archival medical history, contact with relatives.
Somatic status.
The condition is satisfactory.
The physique is normosthenic. Height 162 cm, weight 52 kg.
The skin is of normal color, moderately moist, turgor is preserved.
Visible mucous membranes are of normal color, the pharynx and tonsils are not hyperemic. The tongue is moist, with a whitish coating on the back. The sclera is subicteric, the conjunctiva is hyperemic.
Lymph nodes: submandibular, cervical, axillary lymph nodes 0.5 - 1 cm in size, elastic, painless, not fused with surrounding tissues.
The chest is normosthenic in shape and symmetrical. The supraclavicular and subclavian fossae are retracted. The intercostal spaces are of normal width. The sternum is unchanged, the abdominal angle is 90.
The muscles are developed symmetrically, in moderate degree, normotonic, the strength of the symmetrical muscle groups of the limbs is preserved and the same. There is no pain with active or passive movements.
Respiratory system:
Lower borders of the lungs
Right left
Parasternal line V intercostal space -
Midclavicular line VI rib -
Anterior axillary line VII rib VII rib
Mid axillary line VIII rib VIII rib
Posterior axillary line IX rib IX rib
Scapular line X edge X edge
Paravertebral line Th11 Th11
Auscultation of the lungs With forced exhalation and quiet breathing during auscultation of the lungs in the clino- and orthostatic position, breathing above peripheral parts lungs hard vesicular. Dry “crackling” wheezing is heard, equally pronounced on the right and left sides.
The cardiovascular system.
Heart percussion
Borders Relative stupidity Absolute stupidity
Left Along the midclavicular line in the 5th intercostal space Internally 1 cm from the midclavicular line in the 5th intercostal space
Upper III rib Top edge IV ribs
Right IV intercostal space 1 cm outward from the right edge of the sternum In the IV intercostal space along the left edge of the sternum
Auscultation of the heart: the sounds are muffled, rhythmic, no side sounds were detected. The emphasis of the second tone is on the aorta.
Arterial pressure: 130/85 mm. Hg Art.
Pulse 79 beats/min, satisfactory filling and tension, rhythmic.
Digestive system.
The abdomen is soft and painless on palpation. There are no hernial protrusions or scars. Anterior muscle tone abdominal wall reduced.
Liver along the edge of the costal arch. The edge of the liver is sharpened, smooth, the surface is smooth, painless. Dimensions according to Kurlov 9:8:7.5
Symptoms of Ker, Murphy, Courvoisier, Pekarsky, phrenicus symptom are negative.
The stool is regular and painless.
Genitourinary system.
Pasternatsky's symptom is negative on both sides. Urination is regular and painless.
Neurological status.
There were no injuries to the skull or spine. The sense of smell is preserved. The palpebral fissures are symmetrical, the width is within normal limits. Movements eyeballs in full, horizontal small-swing nystagmus.
Sensitivity of facial skin is within normal limits. There is no facial asymmetry; the nasolabial folds and corners of the mouth are symmetrical.
Tongue in the midline, taste preserved. No hearing disorders were detected. The gait with eyes open and closed is smooth. In the Romberg pose, the position is stable. Finger test: no misses. There are no paresis, paralysis, or muscle atrophies.
Sensitive area: Pain and tactile sensitivity in the hands and body is preserved. Joint-muscular sensation and feeling of pressure on the upper and lower limbs saved. Stereognosis and two-dimensional spatial sense are preserved.
Reflex sphere: reflexes from the biceps and triceps brachii, knee and Achilles muscles are preserved, uniform, and slightly animated. Abdominal and plantar reflexes were not examined.
Sweaty palms. Dermographism is red, unstable.
No pronounced extrapyramidal disorders were identified.
Mental status.
Below average height, asthenic build, dark skin, black hair with slight graying, appearance consistent with age. Takes care of himself: looks neat, neatly dressed, hair combed, nails clean, clean shaven. The patient easily makes contact, is talkative, and smiling. Consciousness is clear. Oriented to place, time and self. During a conversation, he looks at the interlocutor, showing interest in the conversation, gesticulates a little, his movements are fast, somewhat fussy. He is distant with the doctor, friendly in communication, willingly talks on various topics relating to his many relatives, speaks positively about them, except for his uncle, whom he took as an example in childhood and whom he admired, but later began to suspect of a bad attitude towards himself, an attempt to deprive his living space. He talks about himself selectively, almost does not reveal the reasons for his hospitalization in a psychiatric hospital. During the day he reads, writes poetry, maintains good relationships with other patients, and helps the staff in working with them.
Perception. No perceptual disorders have been identified at this time.
The mood is even, during the conversation he smiles and says that he feels good.
Speech is accelerated, verbose, articulated correctly, and phrases are grammatically constructed correctly. Spontaneously continues the conversation, slipping into extraneous topics, developing them in detail, but not answering the question asked.
Thinking is characterized by thoroughness (a mass of insignificant details, details not directly related to to the question asked, the answers are lengthy), slippages, actualization of secondary features. For example, to the question “Why did your uncle want to deprive you of your registration?” - answers: “Yes, he wanted to remove my stamp in my passport. You know, the registration stamp is rectangular. What is yours? I had my first registration in ... year at ... address.” The associative process is characterized by paralogicality (for example, the task “excluding the fourth odd one” from the list “boat, motorcycle, bicycle, car” excludes a boat based on the principle of “lack of wheels”). He understands the figurative meaning of proverbs correctly and uses them in his speech as intended. Content-based thinking disorders are not detected. He manages to concentrate, but is easily distracted and cannot return to the topic of conversation. Short-term memory is somewhat reduced: cannot remember the name of the curator, the “10 words” test does not reproduce completely, from the third presentation 7 words, after 30 minutes. – 6 words.
The intellectual level corresponds to the education received, a lifestyle that is filled with reading books, writing poems about nature, about mother, the death of relatives, about one’s life. The poems are sad in tone.
Self-esteem is reduced, he considers himself inferior: when asked why he didn’t get married, he answers, “What’s the point of producing fools?”; The criticism regarding his illness is incomplete, he is convinced that at present he no longer needs treatment, he wants to go home, work, and receive a salary. He dreams of going to his father in Abkhazia, whom he has not seen since 1971, to give him honey, pine nuts, and so on. Objectively, the patient has nowhere to return, since his relatives deprived him of his registration and sold the apartment in which he lived.
Mental status qualification.
The patient’s mental status is dominated by specific thinking disorders: slippages, paralogicality, updating of secondary signs, thoroughness, attention disorders (pathological distractibility). Criticism of one's condition is reduced. Makes unrealistic plans for the future.
Laboratory data and consultations.
Ultrasound examination of organs abdominal cavity (18.12.2002).
Conclusion: Diffuse changes liver and kidneys. Hepatoptosis. Suspicion of doubling of the left kidney.
General blood test (07/15/2002)
Hemoglobin 141 g/l, leukocytes 3.2x109/l, ESR 38 mm/h.
Cause increasing ESR– possibly the premorbid period of pneumonia diagnosed at this time.
General urine test (07/15/2003)
Urine is clear, light yellow. Microscopy of the sediment: 1-2 leukocytes in the field of view, single erythrocytes, crystalluria.
Rationale for diagnosis.
Diagnosis: “paranoid schizophrenia, episodic course with increasing defect, incomplete remission”, ICD-10 code F20.024
Based on:
History of the disease: the disease began acutely at the age of 26, with delusions of persecution, which led to hospitalization in a psychiatric hospital and required treatment for a year and a half. The plot of the delirium: “three young men in black jackets are watching me and want to take away the black bag that I want to sell.” Subsequently, the patient was hospitalized several times in a psychiatric hospital due to the appearance of productive symptoms (1985, 1993, 2002). During periods of remission between hospitalizations crazy ideas did not express it, there were no hallucinations, but the disturbances in thinking, attention and memory characteristic of schizophrenia persisted and progressed. During hospitalization at the Tomsk Children's Hospital, the patient was in a state of psychomotor agitation, expressed certain delusional ideas about relationships, and stated that “his relatives want to evict him from the apartment.”
Family history: heredity is burdened with schizophrenia on the part of the mother, brother, cousin (being treated at the Tomsk Regional Clinical Hospital).
Current mental status: the patient exhibits persistent disturbances in thinking, which are obligate symptoms of schizophrenia: thoroughness, paralogism, slippage, actualization of secondary signs, uncriticality of one’s condition.
Differential diagnosis.
Among the range of possible diagnoses when analyzing the mental status of this patient, one can assume: bipolar affective disorder (F31), mental disorders due to organic brain damage (F06), among acute conditions– alcoholic delirium (F10.4) and organic delirium (F05).
Acute conditions - alcoholic and organic delirium - could be suspected in the first time after the patient’s hospitalization, when fragmentary delusional ideas of attitude and reform were expressed to him, and this was accompanied by activity adequate to the ideas expressed, as well as psychomotor agitation. However, after the relief of acute psychotic manifestations, the patient, while productive symptoms disappeared, remained obligate symptoms characteristic of schizophrenia: disturbances in thinking (paralogism, unproductiveness, slipping), memory (fixation amnesia), attention (pathological distractibility), and sleep disturbances persisted. There was no data on the alcoholic genesis of this disorder - withdrawal symptoms, against the background of which delirious stupefaction usually occurs, data on the patient's massive alcoholism, undulating course of delirium and perception disorders ( true hallucinations). Also, the absence of data on any organic pathology - previous trauma, intoxication, neuroinfection - in a place with a satisfactory somatic condition of the patient allows us to exclude organic delirium during hospitalization.
Differential diagnosis with organic mental disorders, in which disorders of thinking, attention and memory also occur: there is no evidence for traumatic, infectious, toxic damage central nervous system. The patient does not have any psychoorganic syndrome, which forms the basis for the long-term consequences of organic brain lesions: there is no increased fatigue, no pronounced autonomic disorders, and there are no neurological symptoms. All this, coupled with the presence of disturbances in thinking and attention characteristic of schizophrenia, makes it possible to exclude the organic nature of the observed disorder.
For differentiation paranoid schizophrenia In this patient with a manic episode as part of bipolar affective disorder, it is necessary to remember that the patient was diagnosed with a hypomanic episode as part of schizophrenia during hospitalization (there were three criteria for hypomania - increased activity, increased talkativeness, distractibility and difficulty concentrating). However, the presence of delusions of attitude, disturbances in thinking and attention, uncharacteristic of a manic episode in affective disorder, casts doubt on such a diagnosis. Paralogism, slippage, and unproductive thinking that remain after the relief of psychotic manifestations are more likely to testify in favor of a schizophrenic defect and hypomanic disorder than in favor of an affective disorder. The presence of a follow-up history of schizophrenia also allows us to exclude such a diagnosis.
Rationale for the treatment.
Prescribing antipsychotic drugs for schizophrenia is a mandatory component drug therapy. Given the history of delusional ideas, the patient was prescribed a long-acting form of a selective antipsychotic (haloperidol-decanoate). Given the tendency to psychomotor agitation, the patient was prescribed the sedative neuroleptic chlorpromazine. The central M-anticholinergic blocker cyclodol is used to prevent the development and reduce the severity of side effects neuroleptics, mainly extrapyramidal disorders.
Supervision diary.
10 September
t˚ 36.7 pulse 82, blood pressure 120/80, respiratory rate 19 per minute Getting to know the patient. The patient's condition is satisfactory, he complains of insomnia - he woke up three times in the middle of the night and walked around the department. Depressed mood due to the weather, unproductive thinking, paralogical with frequent slippages, detailed. In the area of attention - pathological distractibility Haloperidol decanoate - 100 mg IM (injection dated September 4, 2003)
Aminazine – per os
300 mg-300 mg-400 mg
Lithium carbonate per os
0.6 – 0.3 – 0.3g
Cyclodol 2 mg – 2 mg – 2 mg
11 September
t˚ 36.8 pulse 74, blood pressure 135/75, respiratory rate 19 per minute The patient’s condition is satisfactory, complaints about poor sleep. The mood is even, there are no changes in mental status. The patient sincerely rejoices at the notebook given to him and reads the poems he has written aloud with pleasure. Continuation of treatment prescribed on September 10
September 15th
t˚ 36.6 pulse 72, blood pressure 130/80, respiratory rate 19 per minute The patient’s condition is satisfactory, no complaints. The mood is even, there are no changes in mental status. The patient is glad to meet you and reads poetry. Tachyphrenia, speech pressure, slipping up to the point of fragmented thinking. Unable to eliminate the fourth extra item from the presented sets. Continuation of treatment prescribed on September 10
Expertise.
Labor examination The patient is recognized as disabled group II, re-examination in in this case is not required given the duration and severity of the observed disorder.
Forensic examination. Hypothetically, in the event of committing socially dangerous acts, the patient will be declared insane. The court will decide to conduct a simple forensic psychiatric examination; Taking into account the severity of existing disorders, the commission may recommend compulsory inpatient treatment in the TokPub. Final decision the court will rule on this issue.
Military expertise. The patient is not subject to conscription into the armed forces of the Russian Federation due to the underlying disease and age.
Forecast.
IN clinical aspect managed to achieve partial remission, reduction of productive symptoms and affective disorders. The patient has factors that correlate with a good prognosis: acute onset, the presence of provoking moments at the onset of the disease (dismissal from work), the presence affective disorders(hypomanic episodes) late age started (26 years old). However, the forecast in terms of social adaptation unfavorable: the patient has no housing, connections with relatives are disrupted, persistent disturbances in thinking and attention persist, which will interfere with work activity in the specialty. At the same time, the patient’s basic work skills are intact, and he enjoys participating in intra-hospital work activities.
Recommendations.
The patient needs continuous long-term treatment with selected drugs in adequate dosages, with which the patient has been treated for a year. The patient is recommended to stay in a hospital setting due to the fact that his social connections are disrupted and the patient does not have his own place of residence. The patient is indicated for creative self-expression therapy according to M.E. Stormy, occupational therapy, since he is very active, active, wants to work. Recommended work activity– any, except intellectual. Recommendations to the doctor – work with the patient’s relatives to improve the patient’s family ties.
Used Books.
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