TEERTHANKER MAHAVEER COLLEGE

OF NURSING
Teerthanker Mahaveer University, Moradabad
Mental Health Nursing

Mental status examination

OCD

Submitted to
Submitted by
Mr. Mahantesh Kargi
HOD Ms Provika
Dept of Psychiatric Nursing I Msc Nursing
TMCON, TMU Dept of Psychiatric Nursing
TMCON, TMU
 A. PSYCHIATRIC HISTORY

1. Identification data
 Name: Ms.Sunita
 Age: 22 yrs
 Gender: Female
 Ward: Pavilion 2
 Marital status: Single
 Education: B.A Passed
 Occupation: Nil
 Income: Nil
 Residential address: kudarki
 Religion: Hindu
 Socio economic background: Middle class
 Diagnosis: OCD
 Informants: The informant is her mother (Mrs.Laxmi ). They stay together
since 22 yrs. The information is 90% relevant.

2. Presenting chief complaints:

According to patient:
 Frequently wash hand, washing cloth in several time, checking thought
since 10 months.
 Feeling weakness and anxiety.
 Irregular sleep.
According to informant:
 Disturbed sleep.
 Frequent hand wash and bathing.
 Wash cloths frequently. One soap is finished at a time.
 Unable to do work due to frequent hand washing.
Student record:
 Worried mood
 Disturbed sleeping pattern since 2 weeks.
 Activity intolerance.
 Obsessive compulsive behavior like washer, checker.
Additional points to be recorded by the students are:
 Onset of present illness: Her symptoms are graduallyincreased in nature
  Duration of present illness: Since 10 months.
 Course: Fluctuating.

3. History of present illness:

She was well before 10months. Mainly she is suffered from some repeated action like
hand washing, checking, washing cloth in several time. Other problem like weakness,
disturbed sleep pattern also having since 3 weeks.

4. Past psychiatric history:

Her illness first appeared 10 months back. When she took admission on B.A that time
patient obtained this hand washing& checking action but not frequently. But from
November onwards, this action was increased and disturbed her daily life or
activities. Patient was received treatment from some private centre, Moradabad, least
relief obtained. First time she had been admitted in march 2018 in tmu.

5. Past medical and surgical history:

There are no previous serious medical and surgical history of illness. There are no
history of head trauma, ENT bleeding, fit & unconsciousness etc.

6. Treatment history:
SL GENERIC TRADE DOSE ROUTE FREQUENCY ACTION
NO NAME NAME
1. Pantoprazole Tab. 40mg Oral ODAC Proton Pump
Pantocar Inhibitor (PPI)
2. Olanzapine Tab. 5mg Oral BD Antipsychotic
Oleanz
3. Tab. 25mg Oral OD Tricyclic
Clomipramin
e Clonil antidepressant
Mainly obsessive
compulsive disorder
(OCD)
4. Fluoxetine Tab. 0.25mg Oral BD Antipsychotic
Zomark
5. Methylcobala Inj. 1 amp IM OD Active form of
min Neurokin vitamin B12 which
d is used to treat
anemia as well as
nerve damage with
 numbness, tingling,
pain in various
neurological
disorders.

7. Family history:
 Family structure:
The family is nuclear family. There is no history of consanguineous relationship.
There are 7 family members in her family.

 Family history: There are no history of similar or other psychiatric illnesses,

major medical illnesses, alcohol or drug dependence and suicide or suicide
attempts in his family.

 Current social situation:

 Home circumstances: Healthy home environment is there.
 Per capita income: Total income of her family around 30000.
 Socio economic status: Middle class family.
 Leader of the family: Patient’s father is the leader of the family.
 Current attitude of the family members towards the patient’s illness:
Family members are so supportive and caring.
 The communication patterns in the family range of affectivity, cultural and
religious values and social support system is good.

GENOGRAM:

Patient’sgrandfather Patient’sgrandmother

Patient’s father Patient’s mother

Sister Brother Brother Patient Sister Brother

Key point:

---- Male

--- Female

----Patient

---- Died male

----- Died female

8. Personal history
 Perinatal history: There was no history of any febrile illness, drugs or
alcohol used or psychiatric illness. She was a wanted child of her parent.
Normal full term home delivery was conducted. Birth cry was present. There
was not present post natal complication or birth defect & prematurity.

9. Childhood history
 Primary caregiver was his mother. Exclusive breast feeding was there and
weaning started at 6 months of age. There was normal growth and
developmental milestone.

10. Educational history

 Age of beginning education: At 6yrs of age, she stared her education.
 Academic achievements and relationships with peers and teachers:
Relationships with peers and teachers was good and she was a good student.
 Any school phobia, any learning difficulties: There is no history of school
phobia.
  Reasons for termination of studies: She wants to complete her master degree
also but due to her disease she is unable to took admission.

11. Play history

 She used to play all indoor game with his friends. Relationships with peers was
very good.
12. Puberty
 Age of menarche: 14 years of age

13. Menstrual & obstetric history

 Regulation and duration of menses: Regular
 Length of each cycle: Every 28-30 days.
 No abnormalities is there.

14. Occupational history

 There was no specific occupational history.

15. Sexual and marital history

 She is single so there is no history of sexual and marital history.

16. Premorbid personality (PMP)

 Interpersonal relationship:-She was extroverted. She maintained good
interpersonal relationship with family members, friends social relations.
 Use of leisure time: At leisure time, she used to watch T.V, listening music,
spending time with her family.
 Predominant mood: Optimistic & stable
 Reaction to stressful life events: She handled the situation smoothly
 Attitude to self: Self – confidence level was good.
 Attitude to work and responsibility: She was responsible enough to her work
and responsibility.
 Religious beliefs and moral attitudes: She beleved on god.
 Fantasy life: Daydreaming is not present.
 Habits:
 Food habits: Normal.
 Sleep habit: Irregular.
 B. MENTAL STATUS EXAMINATION

1. General appearance and behavior

 General appearance:
a) Body build & physical appearance: Average build.
b) Looks: Comfortable and looks one’s age.
c) Physical health: Healthy
d) Grooming: She is well groomed, wear clean cloths.
e) Hygiene: Hygiene is maintained, hair combed & nail care also maintained.
f) Dressing: Appropriate
g) Face: Expression is worried.
 Attitude towards the examiner
a) Cooperation: She is co-operative
b) Guardedness: Absent
c) Evasiveness: Absent
d) Hostility: Absent
e) Attentiveness: Attentive
f) Shows interest: Present
 Comprehension: Intact
 Gait and posture: Normal sitting posture.
 Motor activity: Normal
a) Excitement / stupor: Absent
b) Abnormal involuntary movements like tics, tremors: Absent
c) Restlessness/akathesia: Absent
d) Catatonic signs: Absent
 Social manner: Appropriate social manner. Eye contact also maintained.
 Rapport:Working relationship is established with the patient.
 Hallucinatory behavior: Not present

2.Speech
Initiation: Spontaneous
Reaction time: Normal
Rate: Normal
Productivity: Elaborately replies
Volume: Normal
Tone: High
Relevance: Relevant
Stream: Normal
3. Mood and affect
Subjective:
Question: Kese ho aap?
Answer: Patient answered, “Main thik nahi hu”.
Objective: She looks worried.

Predominant mood state: Predominant mood state is anxious.

Mood and affect is appropriate and relevance to situation.

4. Thought:
Stream: normal.
Form: normal.

Content of thought:-
 Delusion:
Q: Kya apko kabhi lagta hai ke log apke bare mein baatien kar rahe hain yea
aapko luksan pochana chahate hai?
A: Nahi
Q: Apko kisi cheez se daar lagta hai?
A: Nahi.
Q: Aapka ghar kha hai?
A: Mera ghar ratlam mein hai.
Inference: kind of delusional thought like persecutory delusion, delusion of grandeur,
delusion of control, bizarre delusion etc. are not present.

 Ideas: There are hopelessness, helplessness present due to her illness.

 Obsession and compulsion:-

Q: Kya aap apke hat bar bar dhote reheti ho?
A: Hain bohot bar.

Q: Kitni bar dhoti ho din me?

A: 15-30 times, koi v cheese chu e se hi… or pata nhi bar bar mujhe hath dhone ki
kheyal ati, main nhi chahati hu pher v control nhi hoti…

Q: kitne din se asa ho rha hai?

A: Pehele itna nhi tha par January se jada ho rha hai.

Q: Kya apke dimag mein koi ek khyal bar bar ata hai jese gas line check kerna?
 A: hain ati hain.
Inference:Obsession and compulsion are present.

 Phobia:
Q. Aapko kisi v chees se dar lagta hai jese panni, jada log, koiye v janwar?
A. Nahi, mujhe asa nhi lagta hai.
Remarks:Phobia or fearfulness is absent.

 Suspiciousness:
Q: Aapko kisiki upor shaak hain?
A: Nahi.
Inference:Suspiciousness is absent in my patient.

5. Perception:
 Illusion:
Q. Yea kya hain?
A. Patient replies, pen hain.

 Hallucination:
Q. Jab aap akele hote hain toh kaan mein kuch ajeeb awaz sunai dete ho ya kuch
cheejein dikhai dete ho?
A: Nahi
Inference: Hallucination and illusion are absent in my patient.

6. Cognative function:

a. Consciousness:She is fully conscious.

b. Orientation

Person: Q: Apke sath kon beita hai?

A: Wo mera maa hai.
Place:Q: Aap abhi kahan ho?
A: Hospital main hu, Moradabad
Time: Q: Abhi time kya hain, kitne baje honge?
A: 2.30pm.
Inference: Patient is fully oriented to place, person and time.

c. Attention/ concentration:

Q: Aap 40 me se 3 minus kijiye?

A:37, 34, 31.
 Q: Aap muje days ke naam batao?
A:Monday,Tuesday,Wednesday,Thursday,Friday,Saturday,Sunday.
Q: Ab dino ke naam ulta batao?
Ans:Saturday, Friday,tursday,Wednesday,Tuesday,Monday. Sunday.

Inference: Patient Attention and concentration is adequate.

d. Memory:
a. Immediate memory
Q: Abhi 5 cheejon ka naam batayenge wo aapko batana hain.(table, chair, bed,
copy, pen)
A: Patient answered correctly
Inference: Immediate memory of the patient is intact.
b. Recent memory
Q: Subaha kinte baje hospital k liye rouana huye the?
A: subha 7 baje.
Inference:Recent memory of patient is intact.
c. Remote memory
Q: Aap kab inter exam pass kiya?
P: 2012.
Inference: Patient’s remote memory is intact.

e. Intelligence:
Q: U.P ka chief minister kon hai?
A: Mr. Akhilesh Yadav.
Q: India ki capital kyahai?
A: Delhi
Inference: Patients’ general knowledge and intelligence is not good.

f. Abstract thinking:
Q: “old is gold” Yeska matlab kya hota hai?
A: Purani cheese acche hote hai.
Q: Pen aur paper me kya antar or samnta hai
A: Pen likhne ke kaam aata hai aur paper me hum likte hai or yea dono chez padhai ke liye jaruri
hain.
Inference: Abstract thinking of the patient is good.

g. Judgement:
a. Test:
Q: Agar abhi is ward me aag lag jaye toh kya karoge?
A: Aag bujhaunga or sbko leke bahar chali jaungi.
Inference: Patient has logical social judgment.

h. Personal:
Q: Yeha se chutti milne ke baad aap kya karoge?
A: main pher se padhai start kanungi
Inference: Patient has good personal judgment.

7. INSIGHT:
Q: Aap mujhe bata sakte hein ki aap hospital mein kyun aaye hain?
A: Aapne ilaz ke liye
Q:Kya aapko lagta hai ki aapko koi manasik bimari ya taklif hain?
A: Main bimar hu, hain lagta hai ki mera mansik bimari hai.
Q:Kya aapko lagta hain ki is bimari ka illaj ho sakta hain?
A:Ha ho to sakta hai.

Inference: Patient hasAwareness of being sick, but attributes it to external or physical factors
Patient insight is 3/6
 TEERTHANKER MAHAVEER COLLEGE OF NURSING
Teerthanker Mahaveer University, Moradabad

History Collection /Mental Status Examination

On
OCD

Submitted to

Mrs.Ranju.V
Asst Professor
Dept of Psychiatric Nursing
TMCON, TMU

Submitted by

Ms. Hina Singh

I Msc Nursing
Dept of Psychiatric Nursing
TMCON, TMU