Forensics History Taking

PSYCHIATRIC CASE WRITE UP – FORENSIC CASE
DEMOGRAPHICS
Date clerked:
Context of where accused was seen: Forensics
Name: Mr M. P.
Age: (DOB )
Sex:
Address:
Tribe:
Language:
Highest level of education:
Employment:
Religion:
Marital status:
Number of children:
CR no:
Case no:
Admitted on … , referred from the Magistrate Court for… in terms of (Sections 77, 78 and 79 of the Criminal
Procedure Act number 51 of 1977)
Charge:
ACCOUNT OF THE CRIME

According to the accused/client
Why was the accused you then arrested by the police? (If they do not want to tell you then you can inform them
of what they did according to the docket.)
What happened?
When year/month/day/time of day. (the accused may not remember then other clues to time of year and time of
day can be used.)
Where? Who? Should all be answered.
This is what happened… lead the patient along if they do not want to talk.
Witnesses present or not?
“The accused states that he was taken into custody thereafter.”
How was the day prior to the crime?

Substance use?
Rule out: (may have influenced the crime)
- Mood disorders:
o DIG FAST (distractibility, insomnia/impulsive behaviours (dancing, singing), grandiosity
(connection with god), flight of ideas/racing thoughts, activity (goal directed)/agitation, speech
(pressured), thoughtlessness)
o M SIG E CAPS: mood, sleep, interest, guilt, energy, concentration, appetite, psychomotor
activity, suicidal activity
- Psychosis: Hallucinations, delusions, disoriented speech or behaviors or negative symptoms(5A)
o Anhedonia, flattened affect, alogia, avolition, attention
- Anxiety: Panic attacks, fears, obsessions
- Feelings and mood
Since the incidence how has the accused felt?
Any suicidal or homicidal ideations currently? SAD PERSONS
Systematic review
Past psychiatric history

“have you ever been treated or diagnosed for any mental illness, … anxiety or depression
Past medical and surgical history
Past drug and alcohol history

- CAGE questionaire
Forensic history:
Family history
Personal history
- Developmental
- Educational
- Occupational
- Psychosexual and relationships
- Current social circumstances
- Pre morbid personality
2
MENTAL STATE EXAMINATION
Appearance:
Behavior:
- Attitude:
- Activity:
Speech:
Mood:
Affect:
Vegetative symptoms:
Thought form:
Thought content:
Perception:
Cognition:
Sensorium:
Attention:
Concentration:
Orientation:
Memory:
 Immediate: repeat three objects: “House, Car, Dog”
 5- minute recall: 3/3
 Short term: recall what he had for breakfast that morning (confirmed).
 Long term: remember who the first president of Namibia was.
Intelligence/ General knowledge: Knows who the first president of Namibia was.
Abstract thinking: able to give the difference and similarities between a bicycle and a car.
Language:
Judgment:
- Test: Specific question
o “what would you do if you find a child playing with matches?
- Social: relationship and if anything is affecting his relationships
- Personal: ask client about life, about his future goals after D/C. ask about illness (how he is coping, how
are the medicines helping or if there are any difficulties taking his medicine)
Insight:
Q1: do you believe you have a mental illness?
Q2: are you still willing to take your meds?
Q3: what will happen if you stop taking your meds?
1. Complete denial of illness
2. Slight awareness of being sick and needing help but denying it at the same time
3. Awareness of being sick but blaming it on others, on external events, on medical or unknown organic
factors
4. Intellectual insight- admission of illness and recognition that symptoms or failures in social judgment
are due to irrational feelings or disturbances; without applying that knowledge to future experiences.
SADPERSONS (modified): (sex, depression, single, organized attempt, ambivalent about future intent)
3
PHYSICAL EXAMINATION
- Vitals:
- General examination:
- Neurological examination:
- Cardiovascular examination:
- Respiratory examination:
- Abdominal examination:
CASE SUMMARY
Multi- Axial diagnosis
Diagnostic Formulation
- Axis I: Psychiatric disorder

- Axis II: Intellectual Development Disorder/Mental Retardation and Personality Disorder
- Axis III: General Medical Conditions “no gross medical abnormality”
- Axis IV: Psychosocial and environmental problems
- Axis V: Global Assessment of Functioning (GAF Scale: 0 – 100)
AETIOLOGICAL FORMULATION
Biological Psychological Social
Predisposing
Precipitating
Perpetuating
Protective
PROGNOSIS
Good prognostic factors Poor prognostic factors
CONCLUSION
- In terms of Section 77 of the Criminal Procedure Act number 51 of 1977, the accused is fit to stand trial
and able to follow court proceedings. (OR VICE VERSA)
- In terms of Section 78 of the Criminal Procedure Act number 51 of 1977, the accused is accountable for
the crime. (OR VICE VERSA)
- In terms of Section 79 of CPA, the accused committed the crime realizing that it was a crime (OR VICE
VERSA)

Forensics History Taking

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Forensics History Taking

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PSYCHIATRIC CASE WRITE UP – FORENSIC CASE

ACCOUNT OF THE CRIME

How was the day prior to the crime?

Past psychiatric history

Past medical and surgical history

Past drug and alcohol history

Multi- Axial diagnosis

- Axis I: Psychiatric disorder

Biological Psychological Social

Good prognostic factors Poor prognostic factors

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