Mental diseases: a public health problem. James Vance May
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of time in different positions, reasons for change, etc.
6. Alcoholism and Other Toxic Influences:
Intemperate, moderate or total abstainer? If intemperate, age at which drinking began, apparent cause of same, kind of beverage consumed and approximate amounts. Periodic or steady drinker? Usual reaction to alcohol?
Inquire about attacks of neuritis, delirium, hallucinatory episodes, suspicions, ideas of jealousy.
Other toxic influences: Drug habits, occupational poisons, lead, arsenic, phosphorus, mercury, etc. Illuminating gas poisoning, nicotine intoxication.
7. Mental Make-up or Type of Personality:
Very important because certain of the non-organic psychoses appear to be a further development of mental traits or tendencies early recognized as personal peculiarities or deviations from the normal. In addition to the points already covered under the preceding headings, the following important types should always be borne in mind and appropriate inquiries made:
Manic make-up: Lively, active, sociable, pushing, talkative, cheerful, optimistic; may be domineering, irritable and inclined to cruelty; sometimes not very efficient, may be noted as changeable, lacking in persistence, concentration and application. May show transient blue spells or lowering of spirits.
Depressive make-up: Gloomy, worrisome, blue natures who feel continuously inhibited or restrained and unable to make decisions; easily discouraged.
Cyclothymic make-up: Emotionally unstable, either up or down, have blue spells or are unduly cheerful and care-free.
Shut-in make-up: Shy, retiring, self-conscious, bashful, quiet, secretive, seclusive and unsociable. Lack of interest in opposite sex or definite aversion; often prudish and over-particular. Unusual religious interest frequent. Inclined to day-dreaming, show fondness for the abstract and mystical. Odd habits, hobbies or cranky pursuits are common.
Paranoid make-up: Mistrustful, suspicious, tend to misunderstand; unduly sensitive, feel discriminated against and have feelings of self-importance. (These traits may be related to shut-in tendencies.)
Other types of make-up include the psychasthenic, neurasthenic and hysterical; also the mentally retarded or undeveloped (feebleminded).
8. Previous Attacks of Mental Disorder:
Obtain dates, places where treated, apparent cause, duration of attacks and general character of symptoms.
9. Precipitating Cause of Present Psychosis:
Try to determine what occurrence or situation appeared to bring about the mental breakdown. Emotional strains, excitement, quarrels, worries, griefs, disappointments, sexual episodes, separation, deaths, childbirth, etc., financial loss, overwork, physical disease, etc.
10. Onset and Symptoms of the Psychosis:
Take as far as possible a spontaneous account beginning with date when first symptoms were noticed in the patient. In this connection particular attention should be given to changes in behavior, in mood, in manner of speech, in attitude towards others and towards work.
Appearance of suspicious, unusual interests, peculiar ideas and delusions?
Hallucinations in various fields and reaction to them?
Obtain as much as possible regarding trend of patient's ideas, topics of conversation and content of hallucinations. What did voices say? What was seen in visions?
Forgetfulness, impairment of memory, loss of orientation and clouding of sensorium.
Always inquire regarding suicidal inclinations or attempts, threats of violence, assaults or homicidal tendencies.
Compare informant's statement with those given in the commitment certificate.
What treatment was given at home? Name of physician in attendance?
Date on which patient was taken to hospital.
PHYSICAL EXAMINATION
I. GENERAL TYPE, APPEARANCE AND CONDITION:
1. Weight (with or without clothes).
2. Height and general frame.
3. Malformations (wherever possible state the origin); asymmetries of skull, face, body, spine, thorax; form of palate (low, high, asymmetrical, saddle or V-shaped, longitudinal torus).
Ears (adherent lobules, prominent anthelix, satyr-points, large, angle, asymmetry, length, etc.).
Abnormalities of hands, feet, sexual organs.
4. Color of the skin.
Color and quantity of the hair.
Color of the eyes.
General complexion.
5. General nutrition (panniculus and muscles).
6. Condition of the skin and mucous membranes; anemia, jaundice, dropsy, pallor, flushing and cyanosis; eruptions (describe in detail). Trophic disorders.
7. Scars, bruises and moles (size, location, color and origin).
8. Evidence of syphilis: scars, including those of the penis, back of tongue (patches devoid of villi and fissures) and palate; tibial crests; glands of elbow, groins and neck.
9. Signs of gout and rheumatism, goitre or nodes of the thyroid, etc.
10. Temperature, general, and various parts of the body (both sides if indicated as in hemiplegia).
II. NERVOUS SYSTEM:
1. General and subjective sensations and facial expression:
General feeling of well-being or exhaustion, general complaints, weakness, etc.
Vertigo: (constant, occasional, or occurring when the patient walks, or in the dark).
Headache: Whole head or limited space; frontal, vertical, occipital, unilateral, bilateral, deep or superficial; constant or periodic, aggravated at night or by some special cause, as with heat, with or without tenderness of head or spine to touch or pressure. Backache (general or localized).
Ovarian, infra-mammary, lumbar and vertex pains (in hysteria).
Neuralgic pains: (fifth nerve, intercostal nerves, sciatic nerve, with pain points, etc.) and muscular pains.
General or wandering pains: Pains in bones (legs) afternoon or night. Girdle pains. Precordial pains (with or without anxiety).
Zones of hyperesthesia: See below.
2. Eyes:
Expression: lids: obliquity, mongol type, lagophthalmus, protrusion of eyeballs (with or without the Graefe symptom), ptosis; spasm of palpebral muscles.
Movement of eyes, nystagmus, strabismus (divergent or convergent); position and extent of movement of the eyes; double vision (in what direction does the second object move and incline?).
Weakness of the internal rectus (in close focussing).
Conjunctiva, lachrymal canal. Scars of cornea. Arcus senilis. Reflectory iridoplegia.
Size and form of pupils. Residuals or formation of adhesion of iris. Contraction of iris on exposure to strong light; on accommodation (for near vision) and after shutting the eye.
Imperfect sight (reading print), improved or not by glasses, dimness of sight, limitation of field of vision, scotoma, hemianopsia, loss of color sense; anomalies of refraction. Condition of apparatus (cornea, lens, vitreous body). Ophthalmoscopy where indicated (for choked disc, optic atrophy, lesions of the fundus). Field of vision where indicated and possible (reversal of color fields in hysteria; scotomata).
3. Ears:
Discharge, otoscopy. Defect of hearing on one or both sides (use watch and tuning fork).
Conduction through skull. Tinnitus aurium (auscultation