SGT UNIVERSITY

BUDHERA, GURUGRAM

MENTAL STATUS EXAMINATION

AND
HISTORY TAKING
ON
Obsessive Compulsive disorder

SUBMITTED TO:- SUBMITTED

BY:-
Ms. Ruchi Sharma Aparna
PG Tutor Msc.(N) 1st year
Faculty of Nursing 230424006
IDENTIFICATION DATA
Name – Ms. Anita singh
Father Name - Mr. Mahender Singh
Age - 17years
Sex -Female
Religion - Hindu
Address- Nirankari colony, Amritsar
Domicile - Urban
Educational -11th class
Occupation – Student
Marital status -Unmarried
Date of admission – 7-02-2024
Ward -Psychiatry ward
Brought by -Father
Diagnosis – obsessive compulsive disorder

CHIEF COMPLAINTS:-
According to Patient :-
Mujhe gussa aata hn jada aur baar baar ek cheez krne ka mann krta hn × 10 days.
According to informant:-
Bhut gussa ata hai ise aur Bar bar ek hi cheej krti rhti hai ( bar bar page turn krti hai) ×10
days.

History of present illness:

Duration-3 years
Onset- Insidious
Course of illness- Continuous with fluctuations
Intensity: Decreased
Patient was well apparently when 3 years back she started having problem that repetitive
urges to turn pages.

PAST MEDICAL HISTORY: According to patient she had no illness in the past.

PAST PSYCHIATRIC HISTORY:

• Repetitive urges to abuse family members.
• Repetitive, intrusive, against her will, identified her own thoughts and distressing and
associated with guilt feeling.
• She tried to decrease distress by replacing the images by shooting scene going on as movie
shoot or abusing God’s name with name of family members.

FAMILY HISTORY:
❑ History of hypothyroidism in mother and is on tab Levothyroxine 75mcg.
❑ History of hypertension in father.

GENOGRAM:-

GRANDFATHER GRANDMOTHER

FATHER MOTHER

SISTER
SISTER PATIENT BROTHER
FAMLY KEY:-

- MALE

- FEMALE

- PATIENT

- EMOTIONAL ATTACHMENT

 History of depressive episode in sister 2 years back which lasted about 2-3 years due
to disturbed family atmosphere as she was having a love affair with other caste boy
and there were fights between family members, mostly with mother. She had also
tried suicidal attempts twice in past. Not taken any treatment and currently
maintaining well and doing job in Mumbai.

ANY CHRONIC MEDICAL HISTORY OF THE FAMILY/ PSYCHIATRIC

ILLNESS: According to patient sister was having psychiatric illness but according to
family members no family history of psychiatric illness.

PERSONAL HISTORY:
 PARENTAL & BIRTH: Patient was delivered normally through full term normal
vaginal delivery in hospital. She was a planned child. There was no congenital
deformity.
EARLY DEVELOPMENT & GROWTH HISTORY: Patient was perfectly
developed without any birth defects. Parents and other family members show love and
affection to the child. All milestones were achieved at their proper age and time.

CHILDHOOD HISTORY: patient’s growth and development were good. She has
good relations with her friends. She was stubborn since childhood and wanted her
demands to be fulfilled at any cost but used to be outgoing and mix up with other
children.

SCHOOL: She started her schooling at the age of 3 years. She was good in studies
and scored good marks.

INTERPERSONAL RELATION WITH TEACHER/ PEER GROUP: She had good

relations with her friends and teachers.

OCCUPATION: Student.

MARITAL HISTORY: Unmarried

PREMORBID HISTORY:
INTROVERT/ EXTROVERT: She is extrovert.
MORAL STANDARDS: She had positive attitude.
AMBITIONS: She was ambitious.
MOOD: Fluctuating.
SOCIAL INTERPERSONAL RELATIONS: She had good interpersonal relationship with
relatives.
INTELLECTUAL ACTIVITIES: According to patient she had no specific hobby but she
likes reading books and singing songs.
ATTITUDE: Her attitude towards family and life was positive.
FANTASY OF LIFE: According to patient, she had fantasies to become singer.
HABITS: Patient had no habit of smoking and alcohol intake etc.
STRENGTH AND ABILITIES: Before illness, she performs all her activities.
PRE-MORBID PERSONALITY: This is the personality and behaviour of patient before
his illness
1. SOCIAL RELATIONS: Patient was not having satisfactory relations with his family
members but with friends and workmates is satisfactory.
2. HOBBIES: Patient likes to play cricket in his free time. He love to watch old Bollywood
movies.
3. PERSONALITY CHARACTERICTIS: Patient was loving, kind, optimistic, determined
and cooperative. He loves and cares for his child.
4. TEMPERAMENT:- Patient was cheerful and happy before illness.
5. ADDICTION AND HABBITS: Patient was having addiction of smoking.
HABITS:
• Eating pattern : Regular eating pattern
• Sleep Pattern : Regular sleep pattern before having illness.

PHYSICAL EXAMINATION:-
SUBJECTIVE DATA OBJECTIVE DATA
1. GENERAL APPEARANCE Weight : 42 kg ❖ Temperature: 98◦ ❖
Respiration : 22 breaths /min. ❖ Blood
pressure: 120/80mmhg
2. HEAD TO TOE EXAMINATION
A) HEAD Hair is black in color and is equally
distributed. ❖ Dandruff and pediculosis not
present. ❖ No alopecia presents.
B) EYES Visual acuity: Normal. ❖ No sty’s or ptosis
present. ❖ Pupils are round, and reacting to
light and accommodation. ❖ Sclera is red in
color. ❖ Conjunctiva: pink in color.
C)EARS External ears symmetrical, ❖ Hearing
Patient says, “I’ve no hearing problems.” acuity: normal. ❖ No wax collection or
abnormal discharges from ears.
C) MOUTH No lesions are present. Color of the is pink,
Patient says, “I’ve no difficulty in coated ❖ No cracks and stomatitis present.
swallowing.” ❖ Reddish discoloration present. No dental
caresses present. ❖ No gingivitis or gum
bleeding present. ❖ No infection.

SYSTEMIC EXAMINATION
1. CARDIOVASCULAR SYSTEM
➢ Blood Pressure - 130/80 mm Hg ➢ Pulse - 100beats/ minute Inspection – ➢
Cyanosis - Present over the Finger tips and toes ➢ Juglar vein distension - No
distension seen Palpation – ➢ Area of pain - Pain in chest region during respiration ➢
Tenderness - Present Auscultation ➢ Pulse - 100 beats/minute ➢ Heart Sounds -
Normal
2. RESPIRATORY SYSTEM ➢ Use of accessory muscles - Present ➢ Any chest deformity
- No any present ➢ Respiratory rate - 28 breaths/ minute ➢ Rhythm - Disturbed as the patient
is having difficulty in Breathing and breathlessness ➢ Breath Sounds - Normal sounds are
heard when patient breath
3. CENTRAL NERVOUS SYSTEM- Inspection – ✓ Patient is conscious and oriented to
time, place and person ✓ Level of attentiveness - Alert and anxious.
4. G.I. SYSTEM -Inspection – ✓ Colour & texture of lips - dry and brownish ✓ Oral
Hygiene - Coated tongue Palpation – ✓ Pain & tenderness - No ✓ Enlargement - No any
enlargement Percussion – ✓ Presence of air or fluid - No ascites Auscultation – Bowel
Sounds- Normal
5. GENITOURINARY SYSTEM- Inspection – ✓ Discharge - No abnormal discharge
reported by the patient ✓ Redness, if any - No Percussion– ✓ Bowel Distension - Normal
bowel movements and no bowel distension
6. MUSCULOSKELETAL SYSTEM Inspection – ✓ Symmetry of 2 sides of body -
Symmetrical ✓ Spinal deformity - No spinal deformity (like lordosis, Scoliosis, kyphosis
etc.) ✓ Bone deformity - No fracture or another bone deformity Observed e.g. bow legs,
knocked knees ✓ Gait - Normal gait ✓ Posture - Normal posture
7. INTEGUMENTARY SYSTEM Inspection – ✓ Texture - Soft and wrinkled skin ✓
Elasticity - Decreased due to aging 38 ✓ Complexion/Colour - Whitish complexion ✓
Oedema on face - No edema on the face Palpation – ✓ Oedema - No ✓ Tenderness - No
Percussion ✓ Lump or Mass formation in any region (if any) - No any
8. SENSORY SYSTEM ✓ Colour of the eyes - Black ✓ Vision - Loss ✓ Pupils - Normal ✓
External Ear (any discharge or infection) - Normal and responds to light ✓ Hearing - Normal
✓ Nostrils – Normal

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE:
• Facial expression: facial expressions of the client were appropriate. It changes
appropriately with the change of subject.
• She did not show any elation, uncontrollable laughter, fear etc.
• Posture: client’s posture was relaxed.
• Mannerism: patient did not show any mannerism.
• Dress: client was dressed appropriately. Dress was clean and tidy and is appropriate
according to season and occasion.
• Hygiene: Hygiene of the patient is not maintained her hygiene, patient appeared clean &
tidy, nails were cut short.
INFERENCE: Client looked appropriate according to her age. Appeared thin built. His
gait was normal and there was not any physical deformity.
MOOD AND AFFECT
Nurse: Apka mann kaisa rehta hn?
Patient: Mera mann tekh rehta hn.
INFERENCE: Mood is irritable and is appropriate to the affect.
MOTOR DISTURBANCE:
• Overactivity or hyperactivity: client show mild restlessness.
Outcome: overactivity is present.
• Underactivity or motor retardation: client do not show slowing down of activity level
and bodily functions.
Outcome: underactivity is absent.
• Stupor: patient showed progressiveness and is not motionless.
Outcome: stupor is absent.
• Stereotype: patient had not repetition of speech.
Outcome: stereotype is Present
• Compulsive movements or compulsion: patient compelled to carry out a certain pattern
of behavior.
Outcome: compulsion is absent.
• Echopraxia: patient have pathological repetition by imitation of the movements of
another person.
Outcome: echopraxia is absent.
• Negativism: patient was cooperative. She refuses simple requests without apparent
reasons.
Outcome: negativism is absent
• Automatic obedience: patient did show a pathological degree of compliance.
Outcome: automatic obedience is present.
INFERENCE: overactivity, stereotype, automatic obedience is present
DISORDER OF FORM OF THOUGHT
• Circumstantiality: patient includes unnecessary details and explanations before the goal
is reached.
Nurse: Aapke ghar me kaun kaun hai?
Patient: Mom, and I
Outcome: circumstantiality is absent.
• Tangential thinking: patient did not give unnecessary detail and explanation and reached
at the goal finally.
Outcome: tangential thinking is absent.
• Incoherence: patient’s speech was clear and sense can be extracted from her speech.
Outcome: incoherence is absent.
• Irrelevant: patient answer appropriately according to the questions.
Outcome: irrelevant is absent.
• Neologism: patient did not coin or invented own language and words which has special
meaning to the patient.
Outcome: neologism is absent.
• Word salad: patient did not mix isolated, disconnected words in hopeless jumble.
Outcome: word salad is absent.
• Perseveration: patient does not have involuntary and morbid repetition of specific word
or idea that persists in spite of patient’s effort to move to another side.
Outcome: perseveration is absent.
• Ambivalence or ambivalent ideas: patient does not have two contradictory ideas,
emotions, attitude and wishes in mind about something.
Outcome: ambivalent ideas are absent.
INFERENCE: No problem in form of thought
DISORDER OF SPEECH
Intensity: the patient’s voice is normal.
• Pitch: voice is not monotonous, pitch is high.
• Speed: patient speaks normally.
• Spontaneity: patient respond spontaneously.
• Manner: the manner of speaking was informal.
• Reaction of time: the reaction of time was normal.
INFERENCE: Patient pitch is high and respond spontaneously
DISORDER IN CONTENT OF THOUGHT
1. STREAM (FLOW OF THOUGHT:
• Pressure of speech: the rate of speech was normal but some time it is fast that one cannot
understand it.
Outcome: pressure of speech was absent.
• Flight of ideas: patient talk regarding a particular subject matter and does not switch to
another unless it was not asked.
Outcome: Flights of ideas are absent• Retardation:
there is no slowing of speech.
Outcome: retardation is absent.
• Mutism:
patient answer appropriately and is not mute.
Outcome: mutism is absent.
• Aphonia:
patient does not speak in whispering.
Outcome: aphonia is absent.
• Thought block:
patient does not have sudden stoppage of thinking process altogether.
Outcome: thought block is absent.
• Clang association: patient does not say rhythmic words which have sounds same but do not
have meaningful conceptual relationship i.e. hang, bang, tang, sang.
Outcome: clang association is absent.
INFERENCE: No disorder in stream of thought
2. CONTENT
a) Delusions:
• Persecutory delusions:
Patient have fixed false belief that she is being deliberately interfered with, discriminated
against, threatened or otherwise mistreated.
Nurse: Kya aapko aisa lagta hai k koi aapko marna ya nuksaan pahuchana chahta hai?
Patient: Han,mere Ghar wale.
Outcome: persecutory delusions are present.
• Delusions of reference:
Patient have fixed false beliefs that other are talking about her and referring to her.
Nurse: kabhi aapko aisa lagta hai k aapke bare me log baat kar rhe ho?
Patient: Nahi
Outcome: delusions of reference are absent
• Delusions of influence or passivity: patient does not have fixed false beliefs that
enemies are influencing her in many ways or someone else is controlling.
Nurse: Kya aapko lagta hai k kisi ne aapke shareer or vichaar ko vas me kiya hai? Patient:
No, I do not think so.
Outcome: delusion of influence is absent.
• Delusion of sin or guilt: patient does not have fixed false beliefs that she has committed
unforgivable sin.
Nurse: Kya aapko lagta hai k aapne pichlle janam me aisa kaam kiya hai jiske karan aapke
saath yeh sab ho raha hai?
Patient: Rarely.
Outcome: delusion of sin or guilt are absent.
• Hypochondrial delusions: patient does not have a fixed false beliefs or conviction
concerning the presence of disease.
Nurse: Kya aapko aisa lagta hai k aapko koi shareerak bimari hai jo theek nhi ho sakti?
Patient: No
Outcome: Hypochondrial delusions are absent.
• Delusion of grandeur: patient have no fixed false beliefs of great power or wealth.
Nurse: Kya appko aisa lagta hai k aap bahut taakatvaar hai ya paise wale hai?
Patient: lgne ki kya bat hai mai hun.
Outcome: Delusion of grandeur is Present.
• Nihilistic delusions:
Derealization: patient does not have fixed false beliefs that all the things in the environment
are changed or destroyed.
Nurse: Kya aapko aisa lagta hai k sari duniya khatam ho gyi?
Patient: I think that world would come to an end.
Outcome: Derealization is present.
Depersonalization: patient does not have fixed false beliefs that she herself is changed or
destroyed.
Nurse: Kya aapko aisa lagta hai k aapme koi cheej bddl or khatam ho gyi ho?
Patient: Yes
Outcome: Depersonalization is present.
b) Obsessions: patient does not have persistent occurrence of thoughts, ideas, images in her
mind.
Nurse: Aapko lagta hai k aapke mnn me koi vichaar baar baar aata hai?
Patient: Yes
Outcome: obsessions is present.
c) Phobia: patient does not have persistent excessive irrational fear about a real object.
Nurse: Kya aapko kisi insaan ya is jagah se dar lagta hai?
Patient: No, I am not afraid of anybody.
Outcome: Phobia is absent.
d) Preoccupation: patient does not remain preoccupied with the thoughts around a
particular idea.
Outcome: preoccupation is absent.
e) Phantasy or fantasy: patient does not have imaginary or imagination that is
unrecognized or unreal.
Outcome: fantasy was absent.
INFERENCE: Delusion of persecution, delusion of grandeur , derealization ,
depersonalization, obsession are present
DISORDER OF PERCEPTION
a) Illusion: patient does not misinterpret the stimuli or wrong meaning to the object.
Nurse: Aapke pass yeh table par kya Rakha hai?
Patient:Pen
Outcome: illusion is absent.
• Macropsia: patient does not interpret the objects in increased size.
Outcome: macropsia is absent.
• Micropsia: patient does not interpret the objects in decreased size.
20
Outcome: micropsia is absent.
b) Hallucinations:
• Auditory hallucinations: patient does not hear the voices in the absence of auditory
stimuli.
Nurse: Jab aap akele hote ho to aapko koi aawajein sunai deti hai?
Patient: nhi
Outcome: auditory hallucinations are absent.
• Visual hallucinations: patient see a person in the absence of visual stimuli.
Nurse: Jab aap akele hote ho to aapko koi dikhaayi deta hai?
Patient: No, I did not see anybody
Outcome: Visual hallucinations are absent.
• Olfactory hallucinations: patient did not smell anything particularly in the absence of
olfactory stimuli.
Nurse: Jab aap akele hote ho to aako koi smell to nhi aati?
Patient: No
Outcome: olfactory hallucinations are absent.
• Gustatory hallucinations: patient did not have any peculiar taste when there is nothing
in mouth.
Nurse: Kya aapke mooh me koi ajeeb sa swaad aata hai?
Patient: No
Outcome: gustatory hallucinations are absent.
• Tactile hallucinations: patient have tactile sensations in the absence of stimuli.
Nurse: aapko aisa lagta hai k aapke sharer pe koi cheej raing rahi hai?
Patient: No
Outcome: tactile hallucinations are absent.
• Hypnopepnic hallucinations: patient does not have false sensory perception occurring
midway between sleep and awakening.
Outcome: hypnopepnic hallucinations are absent.
• Hypnogagic hallucinations: patient does not have false sensory perception between
falling asleep & being awake.
Outcome: hypnogagic hallucinations are absent.
• Lilliputian hallucination: patient does not have perception of objects reduced in size in
absence of stimuli.
Outcome: Lilliputian hallucination is absent.
• Kinesthetic hallucinations: patient does not have any amputated limb.
Outcome: kinesthetic hallucinations are absent.
• Autoscopic hallucinations: patient does not have sensory experience of herself.
Outcome: autoscopic is absent.
• Extracampine hallucinations: patient does not have sensory experience of stimulus
beyond the sensory field.
Outcome: extracampine is absent.
INFERENCE: No problem in disorder of perception
MEMORY:
• Immediate:
Nurse: Mein 5 naam bolungi…. Pen, pencil, copy, rubber, scale aap mere piche bolna
Patient: pen, pencil. Scale, rubber, copy
Outcome: immediate memory was intact.
• Recent:
Nurse: Raat khaane me kya khaya?
Patient: Chapati dal
Outcome: recent memory is intact.
• Remote:
Nurse: aapke school ka naam kya haal hai?
Patient: Xavier School
Outcome: remote memory is intact.
INFERENCE: Immediate, recent and remote memory are intact
DISORDER OF MEMORY:
• Amnesia: patient cannot recall many events fully.
Outcome: amnesia is absent.
• Paramnesia: there is falsification of memory by distortion of recall.
Outcome: paramnesia is absent.
• Anterograde amnesia: patient is able to recall recent events.
Outcome: anterograde amnesia is absent
• Retrograde amnesia: patient is able to recall past events fully.
Outcome: retrograde amnesia is absent
• Confabulation: patient does not fill the gaps in memory by imaginary or untrue
experiences unconsciously.
Outcome: confabulation is absent.
• Dija vu: patient does not experience of seeing with the feeling that one has seen it before
but does not know when or where.
Outcome: dija vu is absent.
• .Hyperamnesia: patient does not have exaggerated degree of retention and recall.
Outcome: hyperamnesia is absent.
Orientation:
• Time: Nurse: Abhi kitna time hua hai?
Patient:12 o’clock.
Outcome: patient is oriented to time.
• Place:
Nurse: iss samay aap kaha par ho?
Patient: In hospital
Outcome: patient is oriented to place.
• Person:
Nurse: Mein kaun hoon?
Patient: Student
Outcome: patient is oriented to person.
• Concentration:
Nurse: Aap 100 me se 5 baar 7 minus kar k bttayein?
Patient: Its 93, 86, 79, 77, 70
Outcome: concentration is Good.
• Abstract thinking:
Nurse: Table or Chair mein kya frrk hai?
Patient: We sit on Chair and we keep things on table.
Outcome: abstract thinking is good.
• Judgment:
Nurse: Agar raaste mein koi letter mile jispe pta likha ho to aap kya krogge?
Patient: post kr dugi.
Outcome: judgement is good.
• Intelligence:
Nurse: Bharat ki rajdhani kaun si hai? Patient: Delhi
Nurse: Bharat ka pardhan mantri kaun hai?
Patient: Narendara Modi
Outcome: patient has good intelligence level.
• Sleep:
Patient’s sleep has decreased and feels difficult to fall asleep at night.
Insomnia is present.
INFERENCE: Patient is oriented to date, time and person, and has insomnia.
INSIGHT
Nurse: Aapko lgta hn k apjko koi bimare hn?
Patient: hn OCD.
Outcome: insight is present
Nurse: Apko lgta hn dewai aur koi ilaz se aap tekh hun skte hn?
Patient: hn tekh hun skte hu dewai se
Outcome: Internal insight is present (5/6)
EPISODIC DISTURBANCE: patient does not have any attacks of epilepsy, hysterical fits,
impulsiveness, aggression or destructive.
SUMMARY
Miss Anita singh,17yr year Female brought to Psychiatric opd by his family members due to
the complaint of patient is having conflict with my family members, Low mood, Repetitive
urges to count page. She has Repetitive urge, Delusion of persecution, Patient has decreased
sleep, Vital signs are normal and his insight is 5/6(internal insight).
CONCLUSION
The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that
describes the mental state and behaviors of the person being seen. It includes both objective
observations of the clinician and subjective descriptions given by the patient.
Bibliography
1.Townsend C. Mary. “Psychiatric mental Health Nursing”.Jaypee Publishers Pvt limited.8th
edition(2012).Page no: 871-874.
2.Sreevani R. A guide to mental health & psychiatric nursing’’. Jaypee Brothers medical
publishers(p) Ltd. 4th edition(2018). Page no 91,408-410.
3.Ahuja Neeraj. ‘A short textbook of psychiatry.’’ Jaypee Brothers medical publishers(p) Ltd.
7th edition(2011). Page 89-113.