HIMALAYAN COLLEGE OF NURSING

SWAMI RAMA HIMALYAN UNIVERSITY

History Collection
On
Bipolar Affective Disorder

SUBMITTED TO: SUBMITTED BY:

Dr. Grace M Singh Pooja Sijwali
Associate Professor MSc. Nursing 1st year
HCN, SRHU HCN, SRHU
1. Identification Data
Name- Mr. Madhukar Sharma
Age- 32yrs
Sex- Male
Date of admission- 14/02/2024
IPD No- 3298305
Bed No- 14
Diagnosis- Bipolar Affective disorder
Doctor Name- Dr. Robin victor
Educational Status- B.com
Occupation- Priest
Religion- Hindu
Marital Status- Married
Dietary Habits- Non- Vegetarian
Address- 17 Adarsh Nagar Haridwar Uttarakhand
a) Name of Informant – Mr. Rakesh Sharma
Relation with patient - Father

b) Chief Complaints
In patient`s own words: mujhe thakan si mahsus ho rhi hai. Mujhe neend km aati hai or bhuk
bhi kam hi lagti h kahi man nhii lgta hai , alg alg vichar aate hai .
Informant`s own words: kuch dino se bahut jyada gussa kr rhe hai kabhi kabhi chid jaate hai or
khana bhi nhii kha rhe the dhng se, kabhi kabhi rone lg jaate hai .

2 ) History of present illness:

a) Time and type of onset :
 Time- 4-5 days
 Mode of Onset- Acute
 b ) Prodromal Symptoms: -
 Disturbance in sleep, Poor appetite, Lack of interest in work, Aggressive
behavior, Excessive thoughts.

c ) Precipitating Factors: -
Biological Factors Psychological Factors Social Factors

Not any Stress Conflicts with family and

peer groups.

d ) Development of symptoms: - Symptoms occurs when patient is stressed about his family
and or having conflict with family members, it’s affect his personal or social life .
e ) Treatment taken and response: - Patient has taken treatment of their symptoms last time
when he admitted on December in Himalayan hospital. The medication which he taken at that
time are: Tab- licab , Tab- valkem , Dose-1500 mg, Time- OD. The treatment was going on for
7-8 days. At that time his condition was improved
3 ) Past psychiatric history: - Patient has history of multiple admission for the same complaints
last admission was on 02- dec- 2024.
Past medical history: - Patient has no medical history

4 ) Family history :

a.) Family Tree:

Key words : -
---- Death
---- Male

---- Female
---- Patient

b. ) Family Table :

Sno. name Age/gender relation education occupation Health

status
1 Mr. 54/ Male Father 9th pass Priest Healthy
Rakesh
Sharma
2 Mrs.Indu 48/Female Mother 5th pass Homemaker Healthy
Sharma
3 Mr. 32/ Male patient B.com Priest Unhealthy
Madhukar
4 Mrs. Rupa 30/ Female wife Graduated Homemaker Healthy
Sharma
5 Rudraksh 12/ Male Son 3rd class Student Healthy

6 Divyansh 05/ Male Son Nursery Student Healthy

Family history & support system :
i) Support system : patient’s family is supportive towards him.
ii) Socioeconomic status : Patient is having well furnished house with proper
ventilation and lightning. His monthly family income is 45,000- 50,000 approx.
iii) Employed member of the family : 2 members, patient and his father.

6) Personal History:

a) Birth & oral development :

i) place of delivery : at home
ii) Mode of delivery : Normal vaginal delivery
iii ) Complication : No any complication are found at the time of delivery.

b) Behavior during childhood :

Patient having normal behavior in childhood no any abnormality is found in childhood
behavior.
c) Physical illness during childhood :
Patient is not having any kind of physical illness during childhood.

d) School :
i) Age of beginning school : 05 year
ii ) Age of Finishing school : 18 year
iii ) Performace : He was good in studies and co-curricular activities in school.
iv ) Attitude: Postive attitude towards classmates and teachers.

e) Occupation :
He is a priest and he is satisfied with his work and income.
f) Sexual history :
Age of puberty : 13 year
Level of knowledge : Appropriate

g) Marital history :
Age at time of marriage : 23 year
Type of marriage : Arrange marriage
Marietal relationship : satisfied & having good relation with wife.
Health status of partner : she is healthy.

h ) Use of alchohol , tobacco & drugs :

He is not taking any kind of drugs, tobacco and alcohol.

7 ) Premorbid personality :
Informant name : - Mr. Rakesh sharma
Relation with patient : Father
a) Social relation : Sometime patient having conflicts with his friends and family.
b) Intellectual activities : He is good in intellectual activities.
c ) Mood : - Appropriate
d ) Character : i) Attitude : polite
ii ) IPR : Maintained
e ) Fantasy life : Day dreaming is not present.
f ) Habits : He is vegetarian, not taking any kind of drugs, alcohol or tobacco.

Conclusion: -
In this history collection I learned about the BPAD disorder , maintained a proper IPR in taking
history from the patient and his attendents and properly collect the history of patient.