History taking
Identification data
Name- Master Atif
Age - 16 Yr
Sex- Male
Bed no.- 3
I.P.D no.- 17012480
Ward- Child psychiatric ward
Education- Illiterate
Occupation - No occupation
Marital status- Single
Religion- Muslim
Address- Dapodi, pune
Diagnosis- Mental Retardation
2. Informant:
Name of the person Relation with the Adequacy Reliability
patient
1. Mrs. Noorjah Mother Adequate Reliable
3.Presenting chief complaints
a). Psychiatric:
According to patient : Restlessness
According to informant: Agressiveness, dora panda, koi kaam na karna,
b). Social: he doesn’t like to interact with others .
c). Interpersonal: he has poor interpersonal relationship
e). Biological: he is having complaints of loss of appetite, decreases sleep
History of present illness
Duration: 3 days
Mode of onset: Acute
Course: Episodic
Intensity: Increasing
Precipitating factors: Fever
Description of present illness: patient was well at the time of birth after 3 months of birth patient
got malaria fever and after some months patient got asthma that was not cure till now when the
patient was of 2 year his mother noticed that he not started to walk and speak also Now patient
came on 31st jan 2025 with the history of fits before 3 days and have the history of abdominal
pain, behavioural changes, the Patient is taking treatment in the psychiatric ward of NIMHANS
Hospital.
Treatment History:
Name of the Chemical Route Frequency Dosage Action
medication name
1.Tab. Consern Olanzapine Orally T.D.S 10mg Anti psychotic
2.Tab. Discern Discern Orally O.D 250mg Anti psychotic
3.Tab. Lorax lorazepam Orally H.S 2mg Sedative
Mental Status Examination
1. General Appearance and behavior
Appearance: looking older
Facial expression: looks sad
Level of grooming: Well kept
Level of cleanliness: inadequate
Level of consciousness: drowsy
Mode of entry: General admission
Co-cooperativeness: Less Co-operative
Eye to eye contact: Not Maintained
Psychomotor activity: Decrease activity
Rapport: Poor Maintained
Gesturing: Normal
Posturing: Patient having no frank posture
Other movement: Patient remain sit some time for long period.
Hallucinatory behavior: Patient has visual hallucinatory behaviour
2. Speech
Initiation: Minimal
Reaction time: delayed
Rate: Slow
Productivity: Pressured
Volume: Decreased volume
Tone: Monotonus
Relevance: irrelevent
Coherence: Fully coherent
Inference: Patient having low volume of speech
Sample: Apka nam kya h. Apke ghar m kon kon h
Patient: Sabu, 2 behan bhai
Inference: No speech disorder is present but patient has alteration in speech.
3. Mood and affect
Subjective:
Nurse : Apka man kaisa hai?
Patient: Pta nai
Objectives:
Patient looks sad
Inference: Affect is inappropriate with mood.
4. Thought:
Stream: Patient was not responding to question .
Form: Patient was not responding to question .
At content level:
Nurse : Kya apko lgta h ki koi apko marna chahta hai?
Patient: Nhi
Inference: Delusion of persecution is absent.
Nurse: Kya apko esa lgta ha ki log apke bare mai bat krte hai?
Patient:
Inference: Patient was not responding to question.
Nurse: Kya apko lgta ha k aap bhot mhan insan ho ?
Patient:
Inference: Patient was not responding to question.
Ideas:
Nurse: Kya apko esa lgta hai ki apki zindagi m kuch b nhi h, aap koi b kam nhi kr skte, koi
apki mdd ni kr skta?
Patient:
Inference: Patient was not responding to question.
Obsessive Compulsive phenomena:
Nurse: Apke mnn m koi khyal bar bar to nhi ata?
Patient:
Inference: Patient was not responding to question.
Phobia:
Nurse: Kya apko kisi chij se drr lgta hai.
Patient: Nhi
Inference: Patient has no phobia
5. Perception:
Illusion:
Nurse: Apko kabhi koi chij m kuch or to dikhai nhi deta?
Patient:
Inference: Patient was not responding to question.
Hallucination:
Nurse: Kya apko akele me koi awaz sunai deti hai?
Patient: Nhi
Inference: Auditory hallucination is not present.
Nurse: Kya apko akele m koi dikhai deta h
Patient: haan hara rang
Inference: Visual hallucination is present.
Nurse: Kya apko esa lgta h ki apke shirr pr kuch reng rha hai?
Patient:
Inference: Patient was not responding to question.
Depersonalization:
Nurse: Apko esa lgta hai ki aap is duniya m ho hi nhi ?
Patient:
Inference: Patient was not responding to question
6. Cognitive Function(Neuropsychiatric assessment)
Consciousness: Patient is not fully conscious.
Orientation:
Nurse: Ye apke pas kon khda h?
Patient: Ye meri maa h
Inference: Patient is oriented to person.
Nurse: Aap is time kha pe ho.?
Patient: Hospital
Inference: Patient is oriented to Place.
Nurse: Aaj kon si date h?
Patient: Pta ni
Inference: Patient is not oriented to time.
Attention
Nurse: Aap mujhe 1-8 tkk ginti sunao?.
Patient: 1------
Inference: Aroused with difficulty.
Concentration:
Nurse: Apke pas 20 rupee ho to usme se 3 rupee 5 bar km kro to kitne rh gye
Patient:
Inference: Patient was not responding to question.
Memory:
Immediate Memory:
Nurse: Teen pen dikhte hue puchti h ye kon se rang k h?
Patient: kala, lal, neela
Inference: Immediate memory is intact.
Recent Memory:
Nurse: Apne kl subah khane m ky khaya tha?
Patient:
Inference: Patient was not responding to question.
Remote memory:
Nurse: Hmara desh kb ajad hua tha?
Patient:
Inference: Patient was not responding to question.
Intelligence:
Nurse: Ek saal m kitne mhine hote h ?
Patient:
Inference: Patient was not responding to question
Arithmetic ability-
Nurse- 16x2 kitne hote h?
Patient-
Inference- Patient was not responding to question.
Abstraction:
Nurse: Iska mtlab btao- Pet m chuhe dodna?
Patient:
Nurse: Acha btao ki copy or dairy m kya smanta h?
Patient:
Nurse: Ankh or kann m kya antrr h?
Patient:
Inference: Patient was not responding to question.
Judgment
Personal
Nurse: Yha se ghar jane k bad kya kroge?
Patient:
Inference: Personal judgment is intact.
Test:
Nurse: Agar do bche apes m ldd rhe ho to aap kya kroge?
Patient:
Inference: Test judgment is intact.
Social Judgment:
Nurse: Aapko agr raste me koi purse pda mile to aap kya kroge?/
Patient:
Inference: Patient was not responding to question
Insight:
Nurse: Aap yha p ku aye ho?
Patient: Pta ni
Inference: Insight(Grade 1) is absent
Indication of play therapy:
Play therapy is a form of counseling or psychotherapy that uses play to communicate with and
help people, especially children, to prevent or resolve psychosocial challenges. This is thought to
help them towards better social integration, growth and development, emotional modulation, and
trauma resolution.
Advantages of play therapy for the patient:
The benefits of Play Therapy include:
Increased confidence and concentration;
The space to communicate problems the child is unable to vocalise;
Helping the child come to terms with past trauma and allowing the child to
move on;
Encouraging imagination and creativity;
Increasing social and communication skills;
Allowing the child to learn from their mistakes in a safe and controlled
environment.
Summary: Master Atif is mild moderately mentally retarded but after this session of play
therapy my patient increased confidence and concentration in adl activities, also it supports him
in increasing his social skills and communication skills.
