College of Nursing
AIIMS Raipur
Subject- Mental Health
Nursing
Mental state examination
ON
“BIPOLAR AFFECTIVE DISORDER”
Submitted to- Submitted by-
Mrs.J.jeayareka Ms. Shalini sahu
Assistant Professor M.Sc. Nursing 1st Year
MENTAL STATUS EXAMINATION
1. Name of the patient : Evendra
2. Age : 26/ year
Sex : male
3. Date & time : 14/12/21.
4. Venue :Central Institute of Psychiatry, Raipur.
5. Language of interview: Hindi
6. Time taken for the interview: 45 minutes
I. Appearance :looks one age.
Gait : Normal
Posture ; Normal
Clothes : clean.
Grooming : well groomed
II. Behavior:
Psychomotor activity :Normal
Rapport :Maintained properly
Posturing :Normal
Hallucinatory behavior Absent
III. Attitude : Negative.
IV. Level of consciousness : Conscious and alert
V. Orientation: He is fully oriented to time, place and
Person.
i. Person
Nurse : Who is sitting near by you?
Patient : My father
Inferences : Oriented to person
ii. Place
Nurse : Where are you now?
Paetient : At Hospital
Inferences :Oriented to place.
iii.Time
Nurse : What is the time now?
Patient : it may be 12 PM.
Inferences : Oriented to time.
VI. Speech and Language:
Initiation: Speaks when spoken to
Reaction time: Normal
Rate: Normal
Productivity: Monosyllabic.
Volume: Normal
Tone: Normal variation
Relevance: Sometimes off target
Stream: Normal
Coherence: Fully coherent
e) Mood
Subjective
Nurse :How is your mood?
Patient : its good
Objective : happy
.
(f) Affect
Fluctuation : Labile
Range : Restricted
Quality : Anxious
Intensity : Blunted
Predominant mood state: irritable
INFERENCES:- appropriate to situation.
(g) Thought
Stream: Normal
Content:
Nurse- What type of ideas comes in your mind?
Patient- normal
Remark -normal
Ideas: normal
Thought alienation phenomenon: not elicited
Phobias: not elisited
Any preoccupation: not elicited
Inferences : Has feeling of helplessness and delusion of persecution is present.
(h) Perception
Illusions:
Nurse:- Pointing toward the wall clock, What is there on the wall?
Patient:- It is a wall clock.
Remark:-no illusion.
Hallucinations:
Nurse:- Do you hear any sound or able to see someone or smellsomething
which is not audible/ visible/ smell to others?
Patient:- no not hear any voice
Remarks:- Auditory hallucinations not present.
Somatic passivity: Nil
Déjà vu/jamia vu: Nil
Depersonalization/ derealisation: Nil
(i) Cognitive Functions
Consciousness : Conscious.
Orientation
iii.Person
Nurse : Who is sitting near by you?
Patient : My sister
Inferences : Oriented to person
iv.Place
Nurse : Where are you now?
Patient : At Hospital
Inferences :Oriented to place.
iii.Time
Nurse : What is the time now?
Patient : it may be 11AM.
Inferences : Oriented to time.
Attention
Nurse : Add 100+10
Patient : Taken few time, then told 110
Inferences : Attention is impaired
Concentration
Nurse : Name the months in backward?
Patient : able to tell
Inferences : normal
Memory
i. Immediate
Nurse : Repeat the word what I say bucket, Pen, mobile, ball
Patient : Pen, mobile, ball, bucket
Inferences : Immediate memory intact.
ii. Recent
Nurse : What you had in your dinner last night?
Patient :Roti and chaval. (same told by his mother)
Inferences : Recent memory intact.
iii. Remote
Nurse : What is your date of birth ?
Patient :
Inferences : normal.
Abstraction
Nurse : How an apple & an orange are similar
Patient : both are fruit
Inferences : abstract thinking is present.
(k) Judgment:
Test:-
Nurse : What will you do if there is fire in this room?
Patient : I will run away from this room
Inferences : Test judgment is present.
Personal test:-
Nurse :what will you do after discharge?
Patient :I will go to my home, & will conitue my study.
Inferences : Personal judgment is present.
Social:-
Nurse :what will you do when a marriage party is there in your
neighbor.
Patient : I will go to attend the marriage
Inferences : Social judgment is normal.
Insight:
Nurse : Do you accept your illness and require treatment?
Patient : Yes, that is the reason for coming here.
Inferences : Grade 6 insight.
Summary:-
Mr Evendra 27 year old divorced male patient. he was not well groomed. he was well behaved,
rapport was easy to build with her. he was conscious . he was oriented to time, place and person.
he was talking in normal speed with normal volume. Patient was looking happy. he was having
congruent mood. Her thought content normal, Stream -no loosening of association is seen.
Possession Recognizes her thoughts as his own. The patient no hallucinations no illusion,
derealization, depersonalization. Concentration and attention is normal with the patient. Insight
of the patient is grade-6. Abstraction is according to socio educational status. Judgement is
normal with the patient.
