HISTORY TAKING
IDENTIFICATION DATA
Name:Mr.ShivkumarVagela
Age:35 year
Sex :Male
Occupation: shopkeeper
Education:8th pass
Mother tongue:gujarati
Income:10,000/-per month
Marital status: single
IP No:17234
DOA : 25/6/2018
Address: vijapur, maheshana
Religion: muslim
Informant: patient self and case record files (CRF)
CHIEF COMPLAINTS
Intake of alcohol since 10 years
Intake of cigarette since 10 years
Intake of afin since 2 years
Increased talk since 2 years
Aggressive behaviour sometimes
Decreased sleep since 6 months
HISTORY OF PRESENT ILLNESS
Mode of onset: insidious
Course: Continuous
Intensity: increased
Duration: 10 years
Precipitating factor: not found
Mr. Shivkumar is 30 years old. He starts to intake of alcohol 10 years before with his
friends setting, initially used 1 glass local mahuva and after that patient starts vomiting and
feels weakness in his body. After that he increased the amount of alcohol 1 bottle (500ml).
Then patient has tried to minimise the intake of alcohol up to 150ml. The last intake was 1
month before. Same way patient started to intake afin with his friends settings. Patient is
1
spending more than 300/- Rs per day for that. Before 1 month, patient had repeated tendency
for intake of substance specially alcohol. If he is not taking the alcohol then patient is not
feeling sleep and become irritable. And he becomes very aggressive on family members and
starts to talk.
No history of blackouts, binge drinking pattern, fits, or flashes backs etc.
Patient has history of abstinence 4 to 5 times. Hesafely understands the causation and
problem associate with alcohol. Then after patient starts the use of alcohol with his friends
without any reason.
HISTORY OF PAST PSYCHIATRIC ILLNESS :
Not significant any psychiatric illness in patient such as depression, mania, schizophrenia etc.
HISTORY OF PAST MEDICAL AND SURGICAL:
Patient has history of Ependicectomy before 5 years.
HISTORY OF OTHER SUBSTANCE ABUSE:
Use of cigarette since 10 years
Use of affine since 2 years
SUMMARY STATEMENT:
Duration of dependence pattern: 4 years
Type of dependence: Active
Last intake: 1 Month before
Physical problem: Yes
Reason for current consultation:
Patient having the problem of sleep and weakness and also he has problem in moving
the hands when he walking. So he thinks to need treatment.
TREATMENT HISTORY
Name of drug Dose Route Side effects
Inj.Lorazepam 2mg IM Nausea, vomiting, vertigo, blurring to
TID vision,epigastric pain, impotence, retrograde
amnesia, diarrhoea
Inj. Thiamin 1amp IM Blue colored lips, chest pain, feeling short of
OD breath, black-bloody-tarry stools, coughing up
blood or vomit that looks like coffee grounds.
Inj.Clonazepam 0.5 mg IM Nausea, vomiting, vertigo, blurring to vision,
1-1-2 epigastric pain, impotence, retrograde amnesia,
diarrhoea
2
FAMILY HISTORY
FAMILY GENOGRAM
KEY WARD
-Male
-Female
-Patient
-Death
Patient’s Father is used the alcohol.
Patient’s brother is using alcohol occasionally.
Patient has poor relation with family members.
No any history of psychosis, mood disorders, epilepsy in the family members.
Not reported any legal issues in the family.
Patient’s father was died before 5 years due to electrical short
Total 4 members in the family.
ACCIDENTS
Accident is reported 2 times in the patient but slightly injured and no need to treatment.
PERSONAL HISTORY
Perinatal History
Antenatal period: no any defect during antenatal period.
Birth: full-term.
Delivery: normal.
3
Birth cry: immediate
No any birth defects and no any postnatal complication
Childhood history
Primary caregiver present: Mother
Feeding: breast feeding
Age at weaning: 5-6 month
Developmental milestone: normal
Behaviour and emotional problem: no any
Educational history
Age at beginning of formal education: 6yr
Academic performance: poor, he was not very intelligent in study.
Relationship with peers and teachers: not good relationship with friends,
School phobia: no
Play history
Relationship with playmates was good. He likes to play cricket.
Emotional problems during adolescence
No any emotional problem during adolescence.
Puberty
Age at appearance of secondary sexual characteristics: 14 yr
Anxiety related puberty changes: no
Occupational history
Age at starting work: 20 yrs
Job held in chronological order: work as driver and not changed
Marital and sexual history
Not applicable
Premorbid personality
(a) Interpersonal relationships: extrovert
(b) Family and social relationship: poor
(c) Use of leisure time: he used to watch TV.
(d) Predominant mood: optimistic, fluctuating.
(e) Usual reaction to stressful events: irritable
(f) Attitude to work and responsibility: he was a responsible person for work
4
(g) Religious beliefs and moral attitudes: he is religious. Hyper religiousness shows
in his behaviour. He believed in RAM and HANUMAN
(h) Fantasy life: not found
(i) Habits:
Eating pattern : regular
Elimination : regular
Sleep : regular
MENTAL STATUS EXAMINATION
[A] General Appearance AndBehaviour
Appearance: looking ones age, tidy
Level of grooming:adequate
Level of cleanliness:adequate
Level of consciousness: Conscious
Cooperativeness:cooperative
Eye to eye contact:maintained
Psychomotor activity:increased
Rapport: established
Gesturing: normal
Posturing: normal posture
Other movements:fine tremors in hand
Hallucinatory behaviour: Auditory hallucination is present.
[B] Speech
Initiation:spontaneous
Reaction time:normal
Rate:slow
Productivity: increased
Volume: loud
Tone: monotonous
Stream: normal
Relevance: sometimes off target
Coherence:coherent speech
5
[C] Mood
Mood- Euphoric
Affect:appropriate
Subjective: “man thik hai”
Objective: appropriate affect
[D] Thought
Stream:normal
Form: normal
Content:normal
Phobia: not present
Obsession/ compulsive phenomena: not present.
[E] Perception:
Illusion: not present.
Hallucination: Auditory hallucination
Patient says that , “ koi mere paise chin lega esi aavaj sunai deti hai”
[F] Cognitive function (neuropsychiatric assessment)
Consciousness:
Conscious
Orientation:
Time: intact
When I asked , “kya aap bata sakte hai is waqt kya time hua hoga?”
he replied, “subah k 10
Place: intact
When I asked, “aapko pata hai aap kaha ho ?”
he replied, “mental hoapital”
Person: intact
When I asked, “mai kon hu?”
he replied , “ sister”
Attention:
Attention is intact .
6
Digit forward and backward.
When I asked , “ 1 se 10 tak gino , fir uski ulti ginti kro.”
He replied, “ 1,2,3......10”
And “10,9,8.....1”
Concentration
Concentration is impaired
When I told the patient to, “do 100-3 and continue to distract it”
He doesn’t reply.
Memory
(a) Immediate: immediate memory is impaired.
When I asked, “chair , board, kursi ,bench
After 2-3 min when I asked him to repeat this word ,
he said that, “chair ,table , tulsi,
(b) Recent: recent memory is impaired
When I asked, “Whathe had taken in his breakfast?”
he replied, “Milk and tea”
(c) Remote: remote memory is impaired
When I asked about his birthday
He said, doesn’t reply
Intelligence
General fund of information: impaired
When I asked, “who is our prime minister?”
He said that, “nahipata”
Arithmetic ability: intact
When I asked , “aap 100 rs leke bajar jate ho aur usme se 60 ki sabji aur 10
Ke biscuit liya to kitne paise vapas milenge?”
He said, “30 rs”
Abstraction
Abstract thinking is impaired
When asked him to tell any proverb and explain it.
He said that , “ nahi pata”
When I asked similarity and dissimilarities between pen and pencil, he has not given
proper answer.
7
[G] Judgment:
Personal judgement-intact
When I asked him, “What will you do after going at home.”?
He said that, “job start karunga.
Social judgement-impaired
when I asked him, “ If you are going in some one’s marriage what will you do?”
he replied, “kuch nahi”
Test judgement-impaired
When I asked him, “If you are going in way and found an envelope with
Address, what will you do of that envelope?
He said, “pata nahi”
[H] Insight:
Grade II
Slight awareness of being sick .
DIAGNOSTIC FORMULATION
Mr. Shivkumar is 35 year old male, single coming from Mheshana. He has no any past
psychiatric illness. Not significant any psychiatric illness in the family. He is taking alcohol
and cigarette since 10 years and also taking affine since 2 years. After that patient has
complains of excessive talking, aggressive behaviour and decreased sleep. so his parents
brought him at mental hospital for treatment. MSE is concluded with increased psychomotor
activity, impaired judgement, impaired concentration, auditory hallucination, grade II insight.
IMPRESSION
Mental and behaviour disorder due to use of alcohol dependence syndrome with psychotic
feature.
8
VADODARA
SUB: MENTAL HEALTH NURSING
TOPIC: MENTAL STATUS EXAMINATION
SUBMITTED TO: SUBMITTED BY:
Ms. Mohini Bariya Ms. Nisha Taviyad
Nursing Tutor 2nd year M.sc nursing
Pioneer Nursing College, Pioneer Nursing
Vadodara college,Vadodara
Roll No: 10
SUBMITTED ON : 14/07/2021
9
10
