MENTAL STATUS EXAMINATION:
a. IDENTIFICATION DATA:
Name : Mr Kuddus Khan
Age : 50 yrs
Sex : Male
Code no : P-280620
Unit : De-addiction Centre
Education :
Occupation : Nil
Marital status : Single
Religion : Muslim
Diagnosis : Severe depression without psychotic symptoms
Address : C\O Kalandar Basha
Gurum Konda
Chittor Dist, Andhra Pradesh
A. General appearance and behavior:
1. General appearance:
- Body built and physical experience: moderately built and healthy, whitish in complexion
- Grooming : well groomed
- Hygiene : not maintained
- Dress : poorly dress and kempt
- Facial expression : smiling
- Eye contact : poorly maintained
- Posture : normal
2. Attitude towards examiner : co-operative
3. Rapport : rapport built not fairly
4. Motor behavior : no abnormal motor behavior like tics and
mannerisms.
B. Thought and speech:
1. Form of thought:
Q. Why do you come here with your wife?
A. I have some problems in order to cure for that.
Inference: normal form of thought.
2. Content of thought
Q. what is your problems?
A. I can’t sleep well and eat well
Inference: no flight of ideas, no OCD.
3. Speech:
- Evaluation of speech: volume, tone and speed normal. Reaction time, prosody and pressure
normal
- Disorder of speech : no aphonia and others disorders
C. Mood and affect:
-Mood: Q. How are you feeling now?
A. I am very sad.
-Affect: patient looks dull and anxious
Inference: affect is congruent to mood.
D. Perception:
Q. when you are alone, are you seeing anything that other person can’t see and hear?
A. no
Inference: absence of auditory hallucinations
E. Sensorium and cognition:
Consciousness: conscious, alert, oriented to time, place and person.
F. Memory
a. Immediate: immediate memory is intact as patient can recall what he talk previous.
b. Recent memory: Q. what you had in breakfast?
A. uppma
Inference: Recent memory is intact.
c. Remote memory: Q. which primary school you studied?
[Link] school
Inference: Remote memory is intact.
G. Attention and concentration:
Q. How many days in a week and tell them?
A. 7 days, he says from Monday to sunday
Q. Subtract 100-5?
A. 95
Reference: Attention is aroused and concentration is also sustained.
H. Orientation:
Q. what must be the time now?
A. it must be 11’o clock
Q. who brought you here?
A. I came along with my brother.
Q. who is that lady wearing white saree?
A. she is a ward sister.
Q. Where are you now?
A. we are in NIMHANS hospital.
Inference: he is oriented to time, place, and person.
I. Abstraction:
Q. what is the different between the table and chair?
A. table is use to write and chair is used to sit.
Q. What is the similarity of banana and orange?
A. both are fruits
Inference: Abstraction is good.
J. Comprehension:
Q. What will you do, if u misses the bus?
A. I’ll catch another bus.
Q. what you will do if you feel cold?
A. I’ll wear sweater.
Inference: comprehension is good.
k. Intelligence:
Q. What is the capital of India?
A. New Delhi
Inference: Intelligent is good.
L. Judgment:
-Personal judgment:
Q. What are you planning to do after discharging from here?
A. I will go for job.
-Social judgment:
Q. What do you wear in marriage ceremony?
A. Marriage dress.
-Test judgment:
Q. What you will you do if your ward is fire?
A. I’ll pour water to stop the fire.
Inference: Judgment of the patient is good.
M. Insight:
Q. Why you are coming and staying here?
A. I have some problem.
Inference: Insight is present.
