HISTORY TAKING
IDENTIFICATION DATA:
Name- Shaoli shoni
Age-27
Sex-Female
Father/spouse- orphan
Address-Bihar
Education-no education
Occupation – no job
Income- no income
Marital status-unmarried
Religion- hindu
Reg no.- IOPK/RG1600028339
Under Dr.- [Link]
Informant-on duty staff nurse
Information-inadequate but relevant
PRESENTING CHIEF COMPLAINT: According to patient-
Amr bhalo lagche naa amr bondhur jonne mon kharaf korche.
Amr sorir ta bhalo nei aktu jor jor lagche
Make aikhane keo bhalo base naa keo make sojjo korte pare naa.
Sobai mare amake aikhane .
Ami niche jbo make jor kore upare eneche
Amr nogra thakle jaiga bhalo lage naa .
Sobai amr jaiga nongra kore
According to informant-
O sobsomoi Oirokom I bole niche bolto amr niche bhalo lagche naa tai take upare phata no
holo diye abr akhon bolche niche jbe.
Oke keo I aikhane mare naa sobai bhalo I baas e .
Or kotha bhoja kubh muskil kubh druto goti tei kotha boli
Nijer jaiga poriskar rakhe onk bar jhat dei ar moche .
Jhogra kore jodi or jaiga keo nongra kore dei
Tobe age porchur jhamela korto ar kubh jedi chilo jodi na kore dito kichu akdin mar pit
korto
HISTORY OF PRESENT ILLNESS:
Duration- 5 years
Mode of onset -Gradual
Course-Continuous
Intensity-Decreasing
Precipitating factors-death of parents at young age, separation from friends of foster home
Drug Trade Dos Rou Mode of Time INDICATION SIDE EFFECTS
Generic e te
name action
name
name
Tab Lorazepa Ativan 2m Ora Facilate the HS ANXIETY UNSTEADI
lorazepam m g l binding of DISORDER NESS
neurotrans INSOMNIA
WEAKNESS
mitter GABA PSYCHOSI
receptor S
CHANGE
through CNS IN
producing APPETITE
calming
affect
Tab Tab Prozac 20m Ora Block the OD MAJOR DRY
g DEPPRESIV MOUTH
fluoxetine l reuptake of
fluoxetine E
serotonin
DISORDER HEART
neurons by
PSYCHOSIS BURN
blocking the PANIC ANXIETY
reuptake of DISORDER
transmitter
protein in
the
presynaptic
terminal.
Tab Tab Trifluop 2mg Ora Causes post HS SCHIZOPHR DIFFICULT
trifluopera eraz l synaptic ENIA Y
trifluopera SHORT URINATIN
zine inhibition of
zine TERM G
dopamine
ANXIETY STUFFED
receptors NOSE
blocking
histamine
and
serotonin
mediated
effects.
Pantapraz- Tab pan40 Pantapra 40 Ora Binds SO Acid Headache
zole Dizziness
mg l irreversibly
ole D reflux Joint pain
to proton
Peptic
pump
thereby
ulcer
reducing
gastric
secretion
Description of present illness- Shaoli was sent from foster home 5 years ago due to
detoriation in mental condition .As per sister on duty she is very sweet but her mood
frequently changes and out of no context start arguing with other patients and Always say she
misses her friend but in reality that person exist or not is still unknown .She always say she is
not treated well but in reality as per my observation she is being treated well and all are
dealing with her very patiently and also very nice to her .Her rate of speech is very high ,
incoherent ,and repetitive. She is always sweeping the floor and always wiping of the dust .
TREATMENT HISTORY:
Drugs:
ECT- NA
Psychotherapy-NA
Family therapy-NA
Rehabilitation-NA
PAST PSYCHIATRIC AND MEDICAL HISTORY:
Number of previous episodes/hospitalization(psychiatric)with onset and course- Not
applicable
Complete or incomplete remission- NA
Duration of each episode-NA
Treatment details and its side effects if any - NA
Treatment outcome- decread
Details of any precipitating factors if present- NA
Substance use details-NA
Surgical procedures/accidents/head
injury/convulsions/unconsciousness/DM/HTN/CAD/Venereal disease/HIV positivity/any
other- Nil
FAMILY HISTORY: No detailed information was find as she is send from foster home so
history of parents and previous generation not find.
Death- parents have died at young age
GENOGRAM
PATERNAL SIDE MATERNAL SIDE
PATIENT (UNMARRIED)
DIED MALE
MALE
DIED FEMALE
PERSONAL HISTORY:
A. Perinatal history-
Antenatal history-Not known
Intranatal history- Type of delivery-Not known
Birth- Not known
Birth cry- Not known
Birth defects- nil
Postnatal complications- Nil
B. Childhood history-
Primary caregiver- not known
Feeding- supplementary feeding
Age at weaning- 8 months
Developmental milestones- Normal
Behavior and emotional problems-Not known
Illness during childhood-Not known
C. Educational history-
Age at beginning of formal education- primary
Academic performance-poor
Extracurricular achievements if any-dancing
Relationships with peers and teachers-not known
School phobia-yes
Look for conduct disorders, for example truancy/stealing-nil
Reason for termination of studies-Not interested in studies .
D. Play history-
Games played(at what stage and with whom)- with friends in foster home
Relationships with playmates- Good
E. Emotional problems during adolescence-
Running away from home/delinquency/smoking/drug-taking/any other-Nil
F. Puberty-
Age at appearance of secondary sexual characteristics-11 years
Anxiety related to puberty changes-Present
Age at menarche-14 years
Reaction to menarche-Anxious
Regularity of cycles, duration of flow-Regular, 4 days flow
Abnormalities if any(menorrhagia, dysmenorrhea)- Nil
G. Obstetrical history-
LMP-10.03.22
Number of children-One girl child
Any abnormalities associated with pregnancy, delivery, puerperium- Nil
Termination of pregnancy-Nil
Menopause-NA
H. Occupational history-
Age at starting work-NA
Jobs held in chronological order-NA
Reasons for changes-NA
Current job satisfaction-NA
Wheather job is appropriate to patients background-NA
[Link] personality
. interpersonal relationship – good
. social relationships – not good
.use of leisure time- Cleaning, dancing
. predominant mood- fluctuating
.usual reaction to stresfull events- anxious and aggressive
. religious beliefs and moral attitude- belief in hindu god .
MENTAL STATUS EXAMINATION FORMAT
A. GENERAL APPEARANCE AND BEHAVIOR:
Appearance: Looking one’s age
Facial expression: Anxious
Level of grooming: Normal
Level of cleanliness: Normal
Level of consciousness: Fully conscious and alert
Mode of entry: Came willingly
Behavior: Normal
Co-operativeness: Normal
Eye-to-eye contact: Maintained
Psychomotor activity: Normal
Rapport: Spontaneous
Gesture: Normal
Posturing: Normal
Other movements: Normal
Other catatonic phenomena: Nil
Conversion and dissociative signs: Nil
Compulsive acts or rituals or habits (for example nail biting) : Nil
Hallucinatory behavior: Nil
B. SPEECH:
Initiation: Spontaneous
Reaction time (time taken to answer the question):Normal
Rate: Normal
Productivity: Elaborate replies
Volume: Normal
Tone: Normal variation
Relevance: Fully relevant
Stream: Normal
Coherence: Fully coherent
Others: Nil
Sample of speech (in response to open-ended questions, verbatim in 2 or 3 sentences: Nurse-
Tumi kar sathe esecho, Client- Amar husband er sathe esechi.
C. MOOD AND AFFECT:
Subjective: Nurse-Halima kemon achho? client-Bhalo achhi didi.
Objective: Patient looks anxious
Predominant mood state: Anxious
Appropriate (relevance to situation and thought congruent)/ inappropriate : Appropriate
D. THOUGHT:
Stream (flow of thought): Normal
Form (formal thought disorder) : Normal
Content:
Delusions: Specify type and give example - Nil
Ideas: Normal
Thought alienation phenomena: Nil
Obsessional/ compulsive phenomena: Thoughts
Phobias (irrational fears) : Nil
Any preoccupations: Not seen
E. PERCEPTION:
Illusions: Nil
Hallucinations (specify type and give example): Nil
Somatic passivity: Nil
Deja vu/ jamais vu: Nil
Depersonalization/ derealization : Nil
F. COGNITIVE FUNCTION (NEUROPSYCHIATRIC ASSESSMENT):
Consciousness: Conscious
Orientation:
Time: Nurse-Ekhon kon samay? Client-Ekhan dupur bela.
Place: Nurse-Tumi kothay esecho? Client-Ami dactar dekhate esechi.
Person: Nurse-Tomar sang eke eseche? Client-Amar bar.
Attention: Nurse-Ami katogulo number balboa mar balar partumi balbe kemon
Digit forward-13,15,17,19,21 client- 13,15,17,19,21
Digit backward-21,19,17,15,13 client-21,19,17,15,13
Attention normally aroused.
Concentration: Concentration normally sustained
100-7: 93,86,79,70….she takes much time for answering
40-3: 37,34,31,28,25
20-1: 19,18,17,16,15
Names of months (backwards): December, November, October
Names of weekdays (backwards): Saturday, Sunday, Monday
Memory:
Immediate (same test as for attention): Nurse-Ami panch ta number balbo 5 minute par tomai
balte balbo-jemon 27316,,Client-panch minute par 27316
Recent: (recent happiness - last meal, visitors, etc) :
Verbal recall - 3 unrelated objects: Nurse- Tumi kal rate ki kheyecho? client-bhat, dal,
soyabean
5 unrelated objects, or imaginary address of 5 items:
Remote:
Personal events: Nurse-Tomar madhyamik esab theke kise besi number chilo? client-
Bhebe niye, life science ee
Impersonal events: Nurse- palashir juddha kato sale hayechilo? client-didimoni sal
mane karte parchi na 1757 na 1857
Illness- related events: Nurse-Tomar pratham jokhan problem hay kar kache
dekhiyechile, client-amar mother in law ojha er kache niye giyechilo.
Intelligence: Intelligence intact
General fund of information: Nurse-Amader pradhan mantri ke? Client-Narendra Modi.
Arithmetic ability: Mental arithmetic/ written sums: Nurse- Tomake 500 taka deoa halo tar
theke tumi 125 takar sabji, 25 takar tel,50 takar phal kinle, tahale tomar kache kato railo? ,
Client-Ektu bhebe niye 30taka railo.
Abstraction:
Normal/ concrete: Normal
Interpretation of proverbs (give a proverb and ask the inner meaning for example, feathers of a
bird flock together/ rolling stones gather no mass): Nurse-Balo to nachte na janle uthon banka
mane tumi ki bojho?, Client-Nije na karte parle onnake dosarope kara.
Similarities between paired objects: Nurse-Balo to ekta tormuj o ekta anaras er madhye mil
kothay? Client-Dutoi to phal.
Dissimilarities between paired objects: Nurse-Balo to mandir o church er madhye amil ki?
Client-Mandire hindu ra jay, church e chirstan ra jay.
Judgement :
Personal (future plans): Nurse-Tumi bari phire giye ki karbe? Client-Ami bari giye meye ke
baper bari theke niye asbo, amar kache rakhte chai.
Social (perception of the society): Nurse-Tumi bus er sit ee base achho, dekhleekjan aged
person todar kache dariye ache tumi ki karbe? Client-Ami sange sange uthe giye aged person
ke sit chhere debo
Test (present a situation and ask their response to the situation): Nurse-Tomar paser barite
agun lagle tumi ki karbe? Client-Agun nivanor chesta karbo, Sabai ke dakbo.
G. INSIGHT:
Insight is rated on a 6 point scale from 1 to 6
1. Complete denial of illness
2. Slight awareness being sick
3. Awareness of being sick attributed it to external or physical factor
4. Awareness of being sick but due to some thing unknown in himself
5. Intelligent insight
6. True emotional insight
DIAGNOSTIC FORMULATION: In my client after history taking and MSE she has obsessional
thoughts, compulsive acts like hand washing repeatedly. These thoughts give no pleasure to her.
She has true insight about the disease. So with comparing with ICD 10, F42 diagnostic evaluation
this is a case of Obsessive Convulsive Disorder.
HISTORY TAKING AND
MENTAL STATUS
EXAMINATION
SUBMITTED TO
Ms. Jhuma Ray SUBMITTED BY
Senior Lecturer Rina Shit
C.O.N, MCH, Kolkata M. Sc Nursing Final Year Student
C.O.N, MCH, Kolkata
