FATHER MULLER COLLEGE OF NURSING

MANGALORE

HISTORY AND MENTAL

STATUS EXAMINATION
OF MRS. SUNANDA
WITH DEPRESSION

SUBMITTED TO: SUBMITTED BY:

MR NAGESHWAR VALERIAN SUDEEP PINTO
LECTURER I MSc PSYCHIATRIC NURSING
DEPT.PSYCHIATRIC NURSING

SUBMITTED ON:17-02-2012
Introduction:
As a part of my clinical postings in psychiatry nursing speciality, I was posted in Nitte
rural psychiatric canter. I came across a client by name Mrs. Sunanda who was came to OPD
with complaints of decreased talk, withdrawn behaviour, decreased sleep, decreased appetite,
irritability and abusiveness.
I selected this patient to know about the patient’s history of illness and to do mental
status examination in order to improve my knowledge and skill in collecting history and MSE
and to learn diagnosis of disease conditions and to help the patient by providing effective care
based on history and MSE.

Interview technique:

The techniques used were direct face to face interview, probing, reassuring, restating,
listening, sympathy, empathy, exploring and work book.

Baseline Proforma:

Name Mrs. Sunanda

Age 38 years
Sex Female
Educational Status 5th std
Marital status Married
occupation House wife
Mother tongue Tulu
Religion Hindu
Date of consultation 14-02-2012
Dr. consultant Dr. Naveenchandra.
Hospital Nitte rural psychiatry canter
Informant Self & husband
Reliability Patient- 70%
Patient husband-90%
Diagnosis Depression
Address Siva Parvaty Nilaya, Kemmannu, Nitte,
Dakshina Kannada.

PRESENT CHIEF COMPLAINTS

Psychotic symptoms Associative symptoms

Irritability- 3 days Not doing house hold Activities- 3 days
Abusive behaviour- 3 days Decreased sleep – 8days
decreased psychomotor activity- 3 days Decreased appetite
Withdrawn behaviour
Onset of present illness: insidious onset & gradually progressive.
Duration of present illness: 10 days
Pre-disposing factors:
 Family history of psychiatric illness (mother and sister are known case of psychiatric
illness).
 Family problems and conflicts
 Father was alcoholic.
 Death of mother.
Precipitating factors: fight with husband and sister in law.
Aggravating factors: Non- compliance towards medication.

History of present illness:

Patient was apparently normal 4-5 days back when symptoms started. Initially noticed
was decreased sleep. Previously patient used to sleep from 10 PM to 6 AM. Now does not
sleep at all at night. No history of day time drowsiness. She keeps walking / pacing around at
night with in the house. She keeps switching off lights and faces light and then turns them on
again. She also keeps disturbing other family members and shouts at them and does not let
them sleep. Patient also noticed to be irritable. She does not listen to any thing that is told to
her. She does not answer questions and walks off when spoken to her. She does not herself
take a bath, clean teeth or combs her hair. Family members have to tell to do so by and only
then do it. Some occasions she does not do personal care duties even if told to do so and has
to be forced to do it.
Patient also does not talk at all from four days she has been silent. She doesn’t
responds to questions or instructions. She does not answer when questioned why she behaves
like this also. She was not taking food, she used to eat only lunch and does not eat dinner.
Patient reports that since 1 year Mrs, Radha is been probably in and she has done
some black magic and had been irritable. She firmly believes that. She also claims that Mrs,
Radha only responsible whatever happens her and her husband.
Patient also says that she used to hear sounds of stones being thrown. Patient was fearful. She
also used abusive words towards Mrs, Radha and her husband and had a fight with them 20
days back. Then she came away from her husband’s home to father’s house and slowly
developed above mentioned symptoms. So she brought to hospital by her brother to get
treatment.

Life chart
 1999

Magico religious
treatment

- Death of mother
- Family history of Non compliance Non compliance
psychiatric illness Family problems Family problems
- Family problems
- Alcoholic father 2010
FMMCPH FMMCPH
1 week 20 days
Dr. K.S. Shetty Dr. K.S. Shetty
 Withdrawn behaviour  Withdrawn behaviour
 ↓ed talk  ↓ed talk
 ↓ed personal care  ↓ed personal care
 irritability  irritability
 abusive and assaultive  abusive and assaultive
behaviour behaviour

Past history of psychiatric illness:

Mrs.Sunanda has a strong family history of psychiatric illness. Her mother as well as
sister are known cases of psychiatric illness. Her mother died due to acute renal failure along
with psychiatric illness. Mrs. Sumalatha is known case of psychiatric illness from past 20
years. She was taking magico religious treatment in the past.
She had a several episodes of psychiatric illness. Exact details of treatment are not
known to patient’s father. He reports that increasing episodes/ frequency with increased
severity is found since 3-4 years.

She again got admitted in FMMCH during 2010 with same complaints as previous
episode which includes withdrawn behaviour, decreased talk, decreased personal care for 3 to
4 days, which was followed by irritability and abusive and assaultive behaviour. Treated by
Dr.K.S. Shetty with She discontinued medications after two months.

Past medical and surgical history:

 No history of head injury, convulsions, unconsciousness, diabetes, hypertension,
coronary artery disease. No significant history of medical, neurological or surgical illness,
surgical procedures, accidents and hospitalization.

Treatment history:

Name of the drug Action Dose Route Frequency

Tab. Lithosun Mood stabilizer 400mg Oral 1-0-1

Tab. Quatipine Anti psychotic 5mg Oral 0-0-1

Family genogram:

FAMILY HISTORY:
 Mrs.Sunanda has a strong history of psychiatric illness in family. Her mother Mrs.
Girija was a known case of mental illness was died in 1990 due to complications of renal
failure, diabetes mellitus and hypertension 20 years back. Her sister Mrs. Rathna was also a
case of mental illness from past 10 years. Her father Mr. Thimmappa is case of alcoholic
since 30 years. No history of suicide and suicidal attempts in family.

SOCIOECONOMIC CONDITION:

Mrs. Sunanda. is living in a joint family. Her husband Mr. Ashok is a construction
worker. She is house wife cum beedi roller. She earns around Rs. 2000/ month. Mr. Ashok is
the leader of the family and he is a decision maker in the family. Inter personal relationship
with husband and other family members are strained due to husband’s critical attitude and
due to her illness.

PERSONAL HISTORY:

Perinatal history:
No history of any febrile illness, medication, drug or alcohol use. No psychiatric
illness during pregnancy. She was born by normal vaginal delivery at home. She was a full
term baby. No perinatal complications like cyanosis, convulsions, jaundice, and birth injuries.

Childhood history:
Patient was brought up by mother. Breast fed till 11/2 years. Weaning started at age of
4 months. No history of maternal deprivation. She attained toilet training at proper age. No
history of neurotic traits like stuttering, stammering, tics, phobias etc.

Educational history:
Schooling started at the age of 6 years. She studied up to 5 th standard. She
discontinued her education because of family problems and mother was frequently fallen
sick. She had many difficulties during her school days. No school phobia, non attendance or
any learning difficulties.

Play history:
She was interested in games but she could not play with other children because of
house hold work. She used help her sister in house hold work as her mother was frequently
fell sick. Her relationship with her friends and opposite sex was normal.

Menstrual history & obstetric history:

She attained menarche at the age of 14 years. She has 30 days of regular cycle and
duration for 3-4 days. She has three children. All three deliveries are full term normal vaginal
deliveries conducted in hospital. Her last daughter is now 6 months old and she is breast
feeding her.

Occupation:
She started working at the age of 14 years. She used to do household works and work
as beedi roller. After marriage also she used to do beedi rolling work. She was earning Rs.
1500 per month.

Sexual and Marital history:

 She did not mention about adolescent sexual activity much. She only mentioned
about her relationship with her husband. She was he was taking care of her with love before.
At present it is difficult to adjust with him because of his critical attitude. No premarital and
extramarital relationships. It was an arranged marriage with parents consent. According to
informants report she got married with force of her mother, she was not interested in
marriage. Duration of marriage life is 18 years. No gender identity disorder or psychosexual
dysfunction.

PREMORBID PERSONALITY:

Interpersonal relationship:
Interpersonal relationship with husband is strained due to his critical attitude and
because of her illness. Her relationship with other family members is also strained due to her
condition.

Use of leisure time:

She spends her leisure time by watching TV at home, speaking with neighbours. She
does not have much intellectual activities.

Predominant mood:
She is pessimistic, prone to anxiety. She is very much reactive to the stressful events.

Attitude towards self & others:

She is having a low self confidence in her, but she was thoughtful about others. She is
not able to admit her failures.

Attitude towards work & responsibility:

She is not able to make quick decisions, but she used to take responsibility of her
family and thoughtful towards others. But due to illness it is impaired at present. She is not
flexible, foresight is present.

Religious beliefs & moral attitude:

She believes in her own religion and follows according to her religion. She have a
tolerance to others beliefs.

Fantasy life:
No sexual and non sexual fantasies. Her dream is to make her children to study up to
PUC.

Habits:
Patient used to sleep 10pm to 6am, due to her illness; she does not sleep at all at night.
Her appetite is decreased. She does not eat usual amount of food. Also eats only lunch and
does not take dinner. No history of alcohol or tobacco use.

PHYSICAL EXAMINATION
Subjective data Objective data
Head and neck Scalp clean: no dandruff
No complaints like injury or infection Lice present, hair equally distributed
Vision: Eye brows equally distributed
She says he is not having any vision problem Eye lids: no edema
Eye lashes: no infection
Conjunctiva: pink in color
Pupil: PEARL
Hearing: No abnormal discharge or infection
No complaints regarding hearing
Speech and orientation She is oriented o time place and person
No difficulty in speaking, she speaks kannada
and konkani
Respiratory system Chest expansion is normal
No report of an cough or dyspnea No discharge from nose
Nostrils are clear
Resp rate 20 breaths / min
Cardio vascular system BP:110/70 mm of hg
No report of chest pain, palpitation, Pulse 76/ min
numbness
Gastro intestinal tract Dental caries present
No complaints Normal bowel sounds
Muscular skeletal system she is not using any supportive devices,
No report of joint pain, weakness etc Normal range of motion of all the limbs and
joints
Nervous system She is not having any abnormal sensation. He
No report of numbness, tingling, sensation is identified sensations.
etc
Integumentary system she is not having any difficulty
No reported abnormalities
Reproductive system She is not having any children and 3
No reported complaints abortions have taken place.
Rest and sleep Sleeping hours 5-6 hrs
She is getting normal sleep
Psychosocial aspects Interaction with people is less
She is lacking family support

Parameters Pt value Normal value Inference

Temperature 98.6F 98.6 F Normal
Pulse 76/ min 60-100/min Normal
Respiration 20/min 16-24/min Normal
Bp 110/70 mm of Hg 120/80 mm of Hg Normal

Conclusion:
Physical examination of Mrs. Sumalatha reveals that she is not having any physical
abnormalities.

MENTAL STATUS EXAMINATION

General appearance & behaviour:
- She is moderately built and healthy appearance.
- She looks uncomfortable and sad.
- She is having a good physical health.
- Grooming- she is poorly groomed and dressed appropriately.
- Hygiene is poor.
- She does not take care of herself unless she is told to do so.
- Her non verbal expression of mood is sad and gloomy and she verbalizes to go home
and feed her baby.

Attitude towards examiner:

- She is conscious & alert, co-operative at times.
- Patient is apathetic & get irritated if asks about her husband.
- No signs of hostility and guardedness present some times.

Comprehension:
She was able to follow the instructions. When i asked how old is your baby and are
you feeding. She answered that she is feeding and her baby is months old. Comprehension is
intact.

Gait & posture:

Her standing, walking and sitting posture is normal and maintains upright position.
She is not having any deformities..

Motor activity:
Motor activity is decreased. She walks slowly, prefers to lie down on her bed most of
the times. No abnormal involuntary movements are noted. No restlessness, akasthesia
mannerisms, waxy flexibility, negativism & echopraxia.

Social manners & verbal behaviour:

Patient seems to have appropriate social manners & she was able to establish and
maintain eye to eye contact during conversation.

Rapport:
A working empathetic relationship was established with some degree of difficulties.

Hallucinatory behaviour:
Hallucinatory behaviours like talking to self, crying without reason was absent. She
was often seen crying. When asked why she is crying, she says she wants to see her kids and
she did not see them from past 20 days and she also says she wants to feed her younger baby.

SPEECH:
 Mrs.Sunanda speaks Kannada and Tulu.
Rate & Quality:
When asked her about herself and hospitalization, she responded spontaneously.
Productivity is decreased. There was no pressure of speech or poverty of speech. Flight of
ideas is absent.

Volume & Tone:

Volume of speech was normal. Sometimes she smiled and sounded happy and
sometimes very sad, seen crying.

Flow & Rhythm:

Flow & Rhythm of speech is smooth. No stuttering, stammering, circumstantialities,
verbigeration, flight of ideas & clang association are absent. Loosening of association are
absent.

Mood & Affect:

When asked the patient ‘how do you feel’ she answered she is fine. But she looked
sad and said she wants go home and want to see her kids. Her stability keeps fluctuating.
Affect range is normal.

THOUGHT:

Stream and flow:

Speech is spontaneous. Thought process is logical and appropriate. There is no
poverty of thought. No thought block, circumstantialities. Circumstantiality, loosening of
associations and Tangentiality are absent.

Content:
The content of thought is less and conveys little information. Delusion of
persecution, Overvalued ideas, ideas of grandiosity, ideas of reference are absent.
Occasionally expresses feelings of helplessness and hopelessness.

PERCEPTION:

Hallucination-
Hallucinations are absent.
Illusion:
No signs of illusion and misinterpretation.
Depersonalization and derealization:
Absent.
Somatic passivity phenomena: absent

COGNITION:

1. Consciousness: Mrs. Sunanda is conscious. No confusion or clouding or stupor.

2. Orientation: she is oriented to time place and person. When I asked about day, date
and year and whom am i and where she is now. She answered correctly.
 Interference: patient oriented to time place and person.

3. Attention: to assess the attention span of patient, i have done digit span test. I asked
her to repeat a set of digits both forward and backward. She was able to do 3 series
forward and two digits backward.

Digits Forward Backward

2 ,9  
4,9,6  ×
5,3,4,1 × ×

Interference: Attention is low.

4. Concentration:

To assess the concentration of patient, i made her to subtract 7 from 100 and
from that 7 and so on. She is able to do serial subtraction test only two series.
100-7=93-7=86.

Inference: her concentration is poor.

5. Memory:

Immediate retention and recall: I showed her 5 things- pen, piece of paper, pencil,
eraser and key chain. I asked her to repeat thrice and told her ask her later. After 5
min when asked her she could answer all five items correctly.
Recent memory: she remembers what she had for breakfast and able to answer for
what she had in the morning.
Remote memory: when i asked her about her date of birth she was not able to
answer. When i asked her about her first child date of birth she answered correctly.
She answered wrongly when asked her about her marriage date. She was able to say
her childhood friend name.

Inference: immediate retention and recent memory in intact. Remote memory is poor.

6. Intelligence:
To assess the intelligence level, I gave simple calculations. She couldn’t do simple
calculations. General knowledge questions like prime minister of India, and who
composed our national anthem. She couldn’t answer. She answered when asked about
Capital of India.

Inference: Her intelligence is poor.

 7. Abstract thinking: I asked her similarity between banana and pine apple, she could
answer that both are fruits. When i asked difference she didn’t answer. When asked
the meaning of proverb ‘all glitters are not gold’ she failed to explain.
Inference: Abstract thinking is poor.

8. Insight: Grade 2: slight awareness of being sick and needing help, but denying at the
same time. She says she is frequently fallen sick due to thinking about her mother,
children and tensions in home.

9. Judgement:
Social judgement: when I asked about what she will do if she got a letter with address and
stamped on the road. She answered she will open the letter and read.
Test judgement: I asked her what she will do if she sees a house on fire. She replied she
gets scared and then try to call for help.

Inference: Social impaired and test judgement is intact.

Formulation:

As I have done the complete history and mental status examination of Mrs. Sunanda I
came to the following evaluation that patient is having a genetic history of psychiatric illness
i.e. her mother and sister is having psychiatric illness. She was also brought up in stressful
situations. At different points of life she had many stressors and precipitating factors and
perpetuating factors too like family adjustment problems, husband’s attitude towards her and
discontinuation of drugs.

According to history collection, MSE and work book, she presents the following
signs and symptoms

 Decreased talk and withdrawn

 Decreased psychomotor activity
 Sadness and irritability
 Abusiveness
 Suspiciousness
 Decreased sleep and appetite
 Decreased personal care
 Abstract thinking is poor
 Decrease in concentration and attention.

From this assessment I made conclusion of this case with the diagnosis of depression (F32)
with differential diagnosis of postpartum depression and depressive episode unspecified.