Mental

status
examination
MENTAL HEALTH AND PSYCHIATRIC nURSING

WARD: CENTRE FOR CHILD AND ADOLESCENT PSYCHIATRY

SUBMITTED TO:

MADAM m. mandal

Senior lecturer

CON, NRSMC&H

SUBMITTED BY:

REETU TAMANG

1ST YR. M.Sc. NURSING

CON, NRSMC&h
 MENTAL STATUS EXAMINATION

a. Name : Rupesh Kr. chowdhuary

b. Age : 16yr.
c. Sex : Male
d. Religion : Hinduism
e. Reg. No. : IDN/6992
f. Education : IX
g. Occupation : Student
h. Marital Status : Unmarried
i. Address : Aurahia Ward No-4
Dhanbag, jharkhand

j. Date of doing M.S.E. : 03. 02 .2016

.k. Place & time of doing

M.S.E. : CCAP of Ranchi at 10 am

2. CHIEF COMPLAINS :

(a) Stated by patient : He has no complain. He is well. He slept

well at last night.

(b) Stated by Mother : Does not sleep at night. He has been

slowing aggressive behavior. He had
not attending school. He assaulted his
family member with sticks, disobedient
and aggressiveness towards parent.
A.GENERAL APPEARANCE AND BEHAVIOR

Appearance : Normal
Facial expression : Pleasant
Level of grooming : Well dressed
Level of cleanliness : Adequate
Level of consciousness : Fully Conscious
Gait and posture : Normal
Mode of entry : persuaded
Behavior : Normal
Psychomotor Activity : Normal
Gesturing : Normal

Height and weight

Attitude towards Examiner
Cooperativeness : Co-operative
Attentiveness : Defensive
Eye to eye contact : not maintained
Rapport : Established with difficulty

Comprehension
Nurse : what is your name ?
Patient : My name is Rupesh kr.chodhuary
Inference : Understanding

Motor Activity
Increased/decreased : Normal
Excitement/stupor : No
Psychomotor activity : Normal
Other catatonic signs : No
Conversion and dissociative signs : No
Hallucinatory behavior : No

B. SPEECH
Initiation : Slow
Reaction time : Slow
Rate : Normal
Productivity :
Volume :
Tone :
Ease of speech :
Relevance :
Coherence :
Goal direction :
Inference :

C. MOOD AND AFFECT

Subjective :
Objective :
Intensity :
Reactivity :
Communicability :
Predominant mood state :
Affect :
Inference :

D. THOUGHT
Stream :
Form :
Content :
Delusions :
Ideas :
Thought alienation phenomena :
Obsessional/compulsive phenomena :
Phobias :
Any preoccupations :
Inference :

D. PERCEPTION
Illusions :
Hallucinations :
Somatic passivity :
Déjà vu/ jamais vu :
Depersonalization/derealization :
Inference :

E. COGNITIVE FUNCTION
Consciousness:

Orientation:
Time
Nurse :
Patient :
Place
Nurse :
Patient :
Person
Nurse :
Patient :

Attention
Digit forward :
Digit backward :

Concentration
Test
Nurse :
patient :
name of months (backwards) :
name of weekdays (backwards) :
inference :

memory
immediate retention and recall (ir and r):

recent:

remote:
personal events :
impersonal events :
illness related events :
inference :

intelligence
nurse :
patient :
inference:

abstract thinking
proverb testing
nurse :
patient :
similarities and difference between familiar objects:
inference:

judgment
the personal judgment
nurse :
patient :
intact/not:
social judgment
nurse :
patient :

test judgment:
nurse :
patient :
inference:

f. insight
grade 1 : complete denial of illness.
grade 2 : slight awareness of being sick and needing help, but denying it at the same time.
grade 3 : awareness of being sick, but it is attributed to external or physical factors.
grade 4 : awareness of being sick, due to something unknown in self.
grade 5 : awareness of being ill and that the symptoms/failures in social adjustment are due to
own particular irrational feelings/thoughts; yet does not apply this knowledge to the
current or future experiences.
grade 6 : awareness leads to significant basic changes in the future behavior.
nurse :
patient :
inference:

diagnostic formulation:

impression: