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CASE STUDY-I
ON
SUBMITTED TO, SUBMITTED BY,
SUBMITTED ON,
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[Link] Content Page No
1 History Collection
2 Mental Status Examination
3 Physical Examination
4 Process Recording
5 Investigations
6 Medications
7 Comparative Picture
8 Nursing Process
9 Psycho-education
10 Summary
11 Conclusion
12 Bibliography
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HISTORY COLLECTION
I. DEMOGRAPHIC DATA
Name :
Age :
Sex :
Education :
Occupation :
Income :
Religion :
Marital status :
Address :
Name of the informant :
Ward :
Diagnosis :
IP No :
Date of admission :
Date of care started :
Date of care ended :
II. INFORMANT HISTORY
Relationship with the patient :
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Duration of stay with the patient :
Interest to take care of the patient :
Reliability :
Adequate :
III. CHIEF COMPLAINTS
1. According to Patient
2. According the Informant
According to patient
[Link] Characteristics Chief Complaints
1. Onset
2. Duration
3. Precipitating
Factors
4. Aggrevating
Factors
5. Relieving
Factors
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According to informant
[Link] Characteristics Chief Complaints
1. Onset
2. Duration
3. Precipitating
Factors
4. Aggrevating
Factors
5. Relieving Factors
PRESENT PSYCHIATRIC HISTORY
1. When the patient was last well-
2. Physiological and Psychological changes with reason-
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3. How the patient brought to the hospital-
4. Present treatment-
5. Any Habits-
6. Negative History-
V. PAST PSYCHIATRIC HISTORY
Draw Diagram
Onset-
Physiological & Psychological changes to as taken place-
Where they took the treatment-
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Satisfied with the treatment-
How they brought to the Psychiatric hospital-
What are the treatment taken-
What is the Reason for Relapse-
Any bad habits-
VI. PAST MEDICAL HISTORY
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________________________________________________________________________
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VII. PAST SURGICAL HISTORY
________________________________________________________________________
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VIII. FAMILY HISTORY
1. Socio Economic, Cultural and Religious background
Who is the breadwinner of the family:
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Monthly income :
Housing pattern :
Own
Rent
Facilities
Type of family :
Nuclear
Joint
Relationship with the Neighbours :
Vegetarian / Non vegetarian :
Religious belief :
Religion :
Moral attitude :
2. Family tree (must include 3 generations)
KEYS
3. Family History of Psychiatric Illness
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Type of Mental Illness :
Relationship with the patient :
Duration :
Treatment :
Prognosis :
Family History of Alcoholism :
PERSONAL HISTORY
I. Perinatal History
Pre Natal
Natal
Post Natal History
(i) Pre Natal History
Check ups :
Immunization :
Exposure to any radiation :
Diet :
Medications :
Maternal Infections :
Attitude towards the Pregnancy:
Interest to carry
Any Force
Reason for hesitation
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(ii) Natal History
Normal delivery/ Abnormal :
LSCS
Forceps
Vaccum
Full term / Any :
Cry after birth :
Meconium, urine passed :
Birth defects :
(iii) Post Natal
Post Natal complications for both Mother and Baby-
II. CHILD HOOD HISTORY
When weaning started :
Who is the primary care giver :
Milestones development :
Behavioral &Emotional problems:
(Thumb sucking, temper tantrums, stuttering, Head banging, Body rocking, Nail
biting, enuresis, Morbid fears, Night terrors, somnambulism)
III. EDUCATIONAL HISTORY
Age of beginning of formal Education :
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Interest to go for school :
Academic performance/ Non Academic performance:
Achievements :
Relationship with teachers and peers :
Truancy :
School Phobia :
Reason for Termination :
IV. PLAY HISTORY
Type of play :
According to the age group :
Relationship with the playmates :
V. PUBERTY
Age of secondary sexual characteristics :
Anxiety related to Puberty changes :
Age at Menarche :
VI. OCCUPATIONAL HISTORY
Age at starting work :
Jobs held in chronological order :
Appropriate to his Educational level :
Interest to go for job :
Job satisfaction :
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Reason for changing :
Relationship with :
Boss
Colleagues
Subordinates
Income :
VII. OBSTETRICAL HISTORY
Regularity of cycle :
Duration of flow :
Any Abnormalities (menorrhagia, Dysmenorrhea):
LMP :
Termination of pregnancy if any (Reason):
Menopause (including any associated problems):
VIII. MARITAL AND SEXUAL HISTORY
Type of Marriage :
Arranged
Love
Interest :
Age of Marriage :
Satisfaction with the marital life :
Sexual Abnormalities :
Relationship with in-laws :
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X. PRE MORBID PERSONALITY
a. Inter personal relationship :
b. Use of Leisure time :
Interest in reading, play, music, movies, creative abilities, spent
alone/with friends
c. Predominant Mood :
d. Attitude to self and others :
e. Attitude to work and Responsibility :
f. Religious beliefs and Moral attitudes :
g. Fantasy life :
Day dreams-
Frequency and content-
Time spent-
h. Habits :
Eating pattern-
Elimination pattern-
Sleeping pattern-
Use of drugs, Tobacco, Alcohol-
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MENTAL STATUS EXAMINATION (MSE)
[Link] APPEARANCE AND BEHAVIOR
1. Appearance :
2. Facial Expression :
3. Posture :
4. Mannerisms :
5. Eye to Eye contact :
6. Rapport :
7. Dressing & Grooming :
8. Psychomotor activity :
9. Other movements :
10. Attitude towards the
Examiner :
II. SPEECH (One sample of speech verbatim in 2 or 3 sentences)
Nurse :
Patient :
Nurse :
Patient :
a. Coherence :
b. Relevance :
c. Volume :
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d. Tone :
e. Rate & Rhythm :
f. Reaction time :
III. MOOD
A. Subjective Mood
Nurse :
Patient :
B. Objective Mood-
Inference :
IV THOUGHT
1. Stream and Form of Thought
Nurse :
Patient :
Inference :
2. Content of Thought
a. Delusion of Grandiosity
Nurse :
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Patient :
Inference :
b. Delusion of Reference
Nurse :
Patient :
Inference :
c. Delusion of Nihilistic
Nurse :
Patient :
Inference :
d. Delusion of Hypochondrial
Nurse :
Patient :
Inference :
e. Delusion of Persecutory
Nurse :
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Patient :
Inference :
f. Delusion of Poverty (Ideas)
Nurse :
Patient :
Inference :
g. Thought Insertion
Nurse :
Patient :
Inference :
h. Thought control
Nurse :
Patient :
Inference :
i. Thought Broadcasting
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Nurse :
Patient :
Inference :
3. Possession of Thought
Obsessive thoughts
Nurse :
Patient :
Inference :
Obsessive images
Nurse :
Patient :
Inference :
Obsessive Ruminations
Nurse :
Patient :
Inference :
Obsessive doubts
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Nurse :
Patient :
Inference :
Obsessive impulses
Nurse :
Patient :
Inference :
Obsessive rituals
Nurse :
Patient :
Inference :
Phobia
Nurse :
Patient :
Inference :
Preoccupied thought
Nurse :
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Patient :
Inference :
V. PERCEPTION
a. Illusion
Nurse :
Patient :
Inference :
b. Hallucinations
Auditory Hallucination
Nurse :
Patient :
Inference :
Visual Hallucination
Nurse :
Patient :
Inference :
Olfactory Hallucination
Nurse :
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Patient :
Inference :
Gustatory Hallucination
Nurse :
Patient :
Inference :
Tactile Hallucination
Nurse :
Patient :
Inference :
VI. COGNITIVE FUNCTIONS
1. Consciousness
Nurse :
Patient :
Inference :
2. Orientation
a. Time
Nurse :
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Patient :
Inference :
b. Place
Nurse :
Patient :
Inference :
c. Person
Nurse :
Patient :
Inference :
3. Attention and concentration
a. Digit forward
Nurse :
Patient :
Inference :
b. Digit backward
Nurse :
Patient :
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Inference :
c. Serial subtractions (100-7)
Nurse :
Patient :
Inference :
4. Memory
a. Immediate
Nurse :
Patient :
Inference :
b. Recent Memory
Nurse :
Patient :
Inference :
c. Remote memory
Nurse :
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Patient :
Inference :
5. Abstract thinking
a. Proverb testing
Nurse :
Patient :
Inference :
b. Similarities
Nurse :
Patient :
Inference :
c. Dissimilarities
Nurse :
Patient :
Inference :
6. Intelligence
a. GK
Nurse :
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Patient :
Inference :
b. Calculation
Nurse :
Patient :
Inference :
7. Judgement
a. Personal judgement
Nurse :
Patient :
Inference :
b. Social judgement
Nurse :
Patient :
Inference :
c. Test judgement
Nurse :
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Patient :
Inference :
8. Insight :
a. Nurse : Where are you?
Patient :
b. Nurse : Why you come here?
Patient :
c. Nurse : Do you have mental illness
Patient :
Inference :
VII. Summary & Clinical Diagnosis
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PHYSICAL EXAMINATION
General Appearance
Body Built :
Gait :
Skin
Colour :
Turgor :
Moisture :
Temperature :
Lesions :
Edema :
Anthropometric Measurement
Height :
Weight :
Body mass index :
Vital signs
Temperature :
Pulse :
Respiration :
Blood pressure :
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Head
Hair :
Scalp :
Eyes
Eyelashes :
Eyelids :
Sclera :
Conjunctiva :
Cornea :
Pupils :
Visual acuity :
Ears
Inspection :
Hearing acuity :
Nose & sinuses
Nose :
Sinuses :
Mouth
Odour :
Lips :
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Teeth :
Gums :
Tongue :
Throat
Inspection :
Neck
Inspection :
Respiratory System
Inspection :
Breathing pattern:
Palpation :
Percussion :
Auscultation :
Cardiovascular system
Inspection & palpation:
Auscultation :
Gastro-Intestinal System
Inspection :
Auscultation :
Palpation :
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Percussion :
Genito-urinary system
Inspection :
Male :
Rectum :
Musculo-skeletal system
Extremities :
Fingers :
Impression
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PROCESS RECORDING
General Objectives
Specific objectives
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Participants Verbatim Non- Verbal Therapeutic Inference
techniques used
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Participants Verbatim Non- Verbal Therapeutic Inference
techniques used
34
Participants Verbatim Non- Verbal Therapeutic Inference
techniques used
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Participants Verbatim Non- Verbal Therapeutic Inference
techniques used
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Conclusion
________________________________________________________________________
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INVESTIGATIONS
S. No Investigations Normal Value Patients Value Remarks
Any other:
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MEDICATIONS
[Link] Name of the Medication D/R/F Mechanism of Action Side Effects Nurses Responsibility
(Generic Name)
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[Link] Name of the Medication D/R/F Mechanism of Action Side Effects Nurses Responsibility
(Generic Name)
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[Link] Name of the Medication D/R/F Mechanism of Action Side Effects Nurses Responsibility
(Generic Name)
D/R/F- Dose/Route/Frequency
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COMPARATIVE PICTURE
Book Picture Patient Picture
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Book Picture Patient Picture
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Book Picture Patient Picture
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POSSIBLE NURSING DIAGNOSIS
1.
2.
3.
4.
5.
6.
7.
8.
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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Assessment Nursing Goals Planning Implementation Evaluation
Diagnosis
Subjective Data
Objective Data
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PSYCHOEDUCATION
Date Topic Signature of the student
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SUMMARY
CONCLUSION
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BIBLIOGRAPHY
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