Identification data
Name:-
Age:-
Sex:-
Address:-
Religion:-
Education:-
Occupation:-
Marital status:-
DOA:-
Socio economic status:-
Background:-
Diagnosis:-
Meaning of diagnosis:-
ICD Number:-
Informant:-
Name:-
Relationship:-
Known to patient since:-
Reliability:-
Presenting complaints with duration:
History of present illness:-
1
Past history:-
Medical
Surgical history:-
Psychiatric history:-
Family history:-
S.no Name of Age Gender Relationship Education Health
. member Status
Family tree:-
Personal history:-
Birth and development:-
I. Antenatal period:-
Uneventful/eventful:-
II. Birth history-
III. Postnatal history:-
IV. Physical health during infancy:-
2
V. Immunization schedule:-
VI. Developmental milestones:-
Motor
Adaptive
Speech
Social (eg. Smile)
Childhood history:-
Adolescence (menstrual history of female):-
Adulthood:-
Marital history:-
Sexual history:-
Occupational history:-
Premorbid personality:-
I. Social relation:-
II. Intellectual activities:-
III.Mood (cheerful, strung up,/optimistic/pessimistic, stable, fluctuating etc.)
3
IV. Character
a. Attitude to work and responsibility
b. Energy and initiativ
c. Habits
Eating food pattern
Sleeping pattern
Excretory pattern
Alcohol consumption
Tobacco consumption
Self medication with drugs
MENTAL STATUS EXAMINATION (M.S.E.)
Data & Time of M. S. E. –
4
Place of M. S. E. –
A. IDENTIFICATION DATA
Name:
Father’s / spouse’s name:
Address:
Age:
Sex:
Caste:
Religion:
Education:
Occupation:
Marital status:
Socio economic status:
Language:
Back ground rural/ urban:
B. AREAS/ COMPONENT
1. General appearance & behavior
Body type:
Appearance:
Level of grooming:
Level of cleanliness
Level of consciousness:
Cooperativeness:
Eye to eye contact:
Psychomotor activity:
Rapport:
Quality of rapport:
Gesturing:
Posturing:
Other movements:
Other catatonic phenomena:
Impression
2. Speech
Initiation:
Speed:
Output:
Pressure of speech:
Volume:
Tone:
5
Manner:
Relevance:
Coherence:
loosening of association/ incoherent
Others:
Impression
3. Thought
Formation:
Progression:
Thought Content:
Obsession:
Compulsion:
Phobia:
Suicidal thought:
Hypochondriacs:
Other: Example:
Impression
4. Mood & Affect
Subject
Objective
Predominate mood state
Range:
Reactivity:
Liability:
Appropriateness:
Congruence:
Emotional expression:
5. Perception
Illusion:
Hallucination:
(If present ask/ write about modalities)
Description:
6. Cognitive function
6
I.Attention:
Normally aroused/ aroused with difficulty
Digit forward
digit backward
II. Concentration:
a. normally sustained/ sustained with difficulty/ distractibility
100-7
40-3
20-1
b. Names of month /week days (backward)
III. Orientation:
Time:
Place:
Person:
IV. Memory:
Immediate:
Recent:
Remote:
V. Intelligence:
Comprehension:
Vocabulary:
General fund of information:
Arithmetic ability:
(Mental arithmetic/ written sum)
VI. Abstraction:
Interpretation of proverbs:
Similarity between paired object:
Dissimilarities between paired object:
Examples:
7
VII. Judgment:
Personal:-
Social :-
VIII. Insight:
Awareness of abnormal behavior /experiences:
Attribution of physical cause:
Willingness to take treatment:
Recognition of personal responsibility:
Summary:
PHYSICAL EXAMINATION
VITAL SIGN’S
Temperature Pulse
Respiration
Blood pressure
Height
Weight
MENTAL STATUS:
Conscious-
Look-
POSTURE:
Body Curves-
Movement-
8
HEIGHT AND WEIGHT:
Height-
Weight-
SKIN CONDITION:
Color-
Texture-
Temperature-
Lesion-
HEAD AND FACE:
Scalp-
Face-
EYES:
Eye Brows-
Eye Lashes-
Eye Lid-
Eye Balls-
Conjunctiva-
Sclera-
Cornea & Iris-
Pupils-
Lens-
Fundus-
Eye Muscles-
Vision-
EARS:
External Ear-
Tympanic Membrane-
Hearing-
NOSE:
External Nores-
Nostrils-
MOUTH AND PHARYNX:
Lip-
Odor of the mouth-
Teeth-
9
Mucus Membrane & Gums-
Tongue-
Throat & Pharynx-
NECK:
Lymph Nodes-
Thyroid Gland-
Range of Motion-
CHEST:
Thorax-
Breath Sound-
Heart-
Breasts-
ABDOMEN:
Observation-
Auscultation-
Palpation-
Percussion-
Manipulation-
EXTRIMITIES:
Movement of joints-
Tremors-
Clubbing of fingers-
Varicose veins-
Reflexes-
BACK:
Spina bifida-
Curves-
GENITAL AND REC TUM:
Inguinal Lymph Gland-
Vaginal discharges-
Hemorrhoids-
Enlargement of the prostate gland-
INTRODUCTION –
10
DEFINITION:-
INCIDENCE:-
RISK FACTORS:-
ETIOLOGY:-
SNO IN BOOK IN MY CLIENT
.
PSYCHOPATHOLOGY:-
11
CLINICAL MANIFESTATION:-
S.NO. IN BOOK IN MY CLIENT
12
DIAGNOSTIC INVESTIGATION:-
SNO IN BOOK IN MY CLIENT
.
13
TREATMENT:-
SNO IN BOOK IN MY CLIENT
.
MEDICAL
14
(MEDICATION)
SURGICAL
THERAPIES
PROCESS RECORDING
PARTICIPATION CONVERSATION INFERENCE
VERBAL NON-VERBAL
15
NURSE
PATIENT/CLIENT
NURSE
PATIENT
NURSING MANAGEMENT
16
NURSING DIAGNOSIS-10
-Assessment-subjective and objective
-Nursing Diagnosis
-Goal
-Intervention
-Implementation
-Evaluation
HEALTH EDUCATION
17
