STUDENTS IDENTIFICATION :- 210000000478

Name Of Institute:- CSMU - panvel

Name of student:- shaikh swaley
Batch:- 2024 - 2025
Name Of Clinical area:- BSC ( hon's ) psychology

Name Of Patient:- manoj suresh kushwah

Registration No :- 271202300024537
Date Of Admission:- 16 - february - 2024
Final diagnosis :- psychosis ( multiple substance abuse )
Date of Selection Of Patient:- 26 - feb - 2024
Type of assignment:- Case History
Submitted to:- Dr Nishi Fatima

IDENTIFICATION OF THE PATIENT:

Name of the patient: - Manoj suresh kushwah

Age : - 28 years Sex :- Male
Date of admission : 16- 2- 24.
registration No:- 271202300024537
Address:- gandhi nagar palghar ( E ) Manor road palghar
Pin - 401404
Phone number- 7756869479
Unit in charge: - Ward no.:- 17 ( A )
Religion: - Hindu Marital status:- non married
Education : - 10 th fail
Occupation:- vegetable vendor
Socio-economic status: - backward
Income: - none
Habitat :-
Language: - Hindi , Marathi
Weight: - 65 kg
Height: - 5 feet 7 inch
Informant: -
Provisional diagnosis: - substance abuse disorder
Finaldiagnosis - substance abuse disorder and psychosis
INFORMANT:- suresh bala kushwah
Name: -suresh bala kushwah
Age: - 64 Sex: - male
Address: - gandhi nagar palghar ( E ) Manor road palghar
Religion: - Hindu
Education: - 10 th fail Income: - 3 lakh annual
Relationship with patient:- father

Reliability: - not so reliae

Intimacy with patient: - none

Length of stay with patient: - 20 years

Attitude towards patient: - not good

Bias with patient: - Yes

Marital status:- married

Occupation: - vegetable seller Socio-economic

status: - backward

I) Presenting Chief Complains:-

As patient verbatim

Angry abusive and asssutive behavior

Reduced sleep

Irritability

Canabis , ganja , charas , brown sugar , alcohol

As Relatives verbatim

Tdi - increase in last 10 to 12 year

Duration:- last 10 to 12 year

Mode of Onset:- 12 years ago

Precipitating Factors:- substance abuse

Treatment Prescribed:- Electro convulsive therapy

Occupational therapy

Supervised medicine

A) General Appearance and Grooming:-

Dress with neatness:- yes

Tidy and clean:- Yes

Cloths appropriate to season:-Yes

Nails, Hair and Grooming:- good

Concern about appearance and hygiene:-not much

B) Attitude:-good

C) FACIAL EXPRESSION:- depressive

D) Posture:- dull

H) Body Built:- average

J) Behaviour:- conscious cooperative and communicable

In the ward with other patients and self:- cooperative

Visitors, at time of meal, at a time of sleep:- cooperative

Aggressive:- not

Abusive:- not

Assaultive:- not
III) VOICE AND SPEECH:-
a) Intensity:- low

b) Pitch:- low

c) Volume:- less

d) Spontaneity:- not continuous

e) Relevancy:- no

f) Productivity:- yes

g) Ease of speech:- average

h) Manner:- good

IV) MOOD AND AFFECT:-

a) Mood:- depressive

b) Affect:- got in substance abuse started consuming - alcohol , ganja ,

charas , brown sugar
Sr. Grading Patient answer Inference
No.
1 Complete Denial Of Illness No

Slight Aware Of Being Sick Yes

2
3 Awareness Of Being Sick Yes
Attributed It To External/Physical
Factor
4 Awareness Of Being Sick But Due No
To Some Unknown In Himself
5 Intellectual Insight Yes
6 True Emotional Insight No

X) BIODRIVES AND GENERAL OBSERVATION:-

Content Question Answer Inference

Appetite

Sleep

Sexual
drive
(Libido)
Elimination

SUMMERY AND CLINICAL DIAGNOSIS OF

MENTAL STATUS EXAMINATION :-
 P.B.DPN COLLEGE RMH,THANE
IDENTIFICATION OF THE PATIENT:
Name of the patient: -
_______________________________________________________
Age : - _________________ Sex :- ______________________
Date of admission : -__________Registration No:-____________
Address:-
_______________________________________________________
_______________________________________________________
Unit in charge: - _________________ Ward no.:- __________
Religion: - _________Marital status:-________________________
Education : - ___________________________________________
Occupation:-_____________________________________________
Socio-economic status: - ___________________________________
Income: -________________________________________________
Habitat: ________________________________________________
Language: - _________________Weight: - ____________________
Height: - _______________________BMI ____________________
Informant: -
________________________________________________________
Provisional diagnosis: -
________________________________________________________
Final diagnosis:-__________________________________________
Criteria of diagnosis: -
_______________________________________________________
MENTAL STATUS EXAMINATION
I. GENERAL APPEARANCE AND BEHAVIOUR

A. ATTITUDE:-

Co-operative

Friendly

Trustful

Attentive

Interested

Defensive

B. GROOMING

DRESSED & NEATNESS

Clean
Tidy

Cloths appropriate to season

NAILS,HAIR GROOMING

Poor

Disfreded

C. HYGIENE

Poor

Fair

Good

D.FACIAL EXPRESSION

Appropriate

Smiling

Frowning

Fearsome

Anxious

Sad

Happy

Anger

Blank

Elation

Close eye, eye to eye contact

Excessive scanning
Preoccupied

INFERENCE

E.POSTURE

Relax

Guarded

Sitting at the edge of chair

Tense posture

Close

Open

INFERANCE

F.GAIT

Normal

Brick

Slow

Unsteady

Dilatory

Gesture

Grimace

Tics

Mannerism

INFERANCE
G. BODY BUILT
Asthenic ( Ectomorph/ Leptosomatic )

Pyknic ( Endomorphic )

Athletic ( Mesomorphic )

II. PSYCHOMOTOR ACTIVITY

Increased

Decreased

Compulsive

Ecopraxia

Stereotype

Negativisms

Catatonia

Muttering

Laughing to self

Difficulty in completing the task

INFERANCE

III. VOICE AND SPEECH

Sample of speech
INTENSITY

Audible

Loud

Soft
PITCH

Monotonous

High Pitch

Low Pitch

VOLUME

Slow

High

Low

SPONTANEITY

Spontaneous

Only when asked

Mute

Relevance speech

Coherence of speech

PRODUCTIVITY:-
Normal

Garrulous

Laconic

EASE TO SPEECH
Under pressure

Blocked

Disorganized

Hesitation

Word salad

MANNER OF SPEECH
Excessive format
Relaxed

Inappropriate

-DEVIATION
Neologism

Echolalia

Clang association

Verbigeration

Mutism

Circumstantiality

Perseverance

Flight of ideas

Aphonia

Tangentiality

INFERANCE:-

IV. MOOD & AFFECT

Sample of speech

Happy

Sad

Worried

Anxious

Irritable

Anger

Detached
 Indifference

Hostility

Liability

Stable

Apathy/Euthimic

AFFECT
a. Pleasurable :- Ectasy
Exaltation

Elation

Euphoric

b. Unplesurable :-
Depressed
Anxiety
Blunt

c. Inadequate affect :-

laugh when need to cry

Ambivalence

Lability

V) Thought:-
a) Nature :-Q-

(Relevent/ Irrelevent)

Sr.No Question Answer Inference

b)Form Q.-
 ( Circumstantiality, Tangentiality,echolalia,verbigaration,flight of
ideas,loosening of assocaiation, incoherence, word salad)

Sr.No Question Answer Inference

c) Stream/Productivity Q.-

(thought block, thought retardation, powerty of ideas, excessive ideas)

Sr.No Question Answer Inference

D) Possession:-
Assess Question Answer Inference
Thought

Control

Withdrawl
Of Thought

Thought
Insertion

Thought
Broadcast

E) Content:-
 Assess Question Answer Inference
Delusion Of
Reference

Delusion Of Grander

Delusion Of
Persecution

Delusion Of Control

Delusion Of Guilt

Delusion Of
Hypochondriasis

Delusion Of Love

Delusion Of Nihilism

Delusion Of Infidility

F) Obsession :-
Sr No. Question Answer Inference

G ) Phobia :-
Sr Question Answer Inference
 No.

H ) Suicidal Thoughts :-
Sr Question Answer Inference
No.

VI) Perception:-
1) Hallucination:-

Type Question Answer Inference

Auditory

Hallucination

Visual
Hallucination

Olfactory
Hallucination

Tactile
Hallucination
Gustatory
Hallucination

Command
Hallucination

2) Illusion:-

Sr Question Answer Inference

No.

3) Depersonalization, if any:-
Sr No. Question Answer Inference

4) Derealisation, if any:-
Sr No. Question Answer Inference

VII) COGNITION AND SENSATION:-

a)Orientation:-

Content Question Answer Inference

Time
Place

Person

b)Memory:-
Content Question Answer Inference

Immediate

Recent

Remote

C) Attention and concentration:-

Sr no. Question Patient answer Inference

Forward
digit span
Test

Backward
digit span
test

Serial
subtraction

Days or
months
counting
 D) Abstract thinking:-

Content Question Answer Inference

Similarity

Difference

Proverb
Testing

E) Intelligence:-

Content Question Answer Inference

General
information

Comprehension

Arithmetic

F) JUDGEMENT:-
 Content Question Answer Inference

Personal

Family

Social

Employment

Test /
situational
 G) INSIGHT:-

Sr. Grading Patient answer Inference

No.
1 Complete Denial Of Illness

2 Slight Aware Of Being Sick

3 Awareness Of Being Sick
Attributed It To External/Physical
Factor
4 Awareness Of Being Sick But Due
To Some Unknown In Himself
5 Intellectual Insight
6 True Emotional Insight

X) BIODRIVES AND GENERAL OBSERVATION:-

Content Question Answer Inference

Appetite

Sleep

Sexual
drive
(Libido)
Elimination

SUMMERY AND CLINICAL DIAGNOSIS OF

MENTAL STATUS EXAMINATION :-