PROFORMA OF PSYCHIATRY HISTORY COLLECTION
1. SOCIO-DEMOGRAPIC DATA:

Name : Mr. Abdullah

Age:

Sex: male

Religion: Muslim

Marital status : single

Education: graduated from medical school

Occupation:

Income/month : 25 000 SR

Address
35 years old
doctor
Residential Address: Jeddah
Communication address-------------
Phone no ----------------

Languages known ----------------
2. Reason for referral / Presenting / chief complaints on admission: In chronological order:
A sad mood, loss of appetite, suicidal ideas and he had been preoccupied thought about the death
almost every night
 B His psychomotor activity, quantity and rate of speech was reduced and he became irritable
 C He stopped all activities he once really enjoyed
 D detached, disturbed in attention and concentration
 E auditory hallucination
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2. Informants:

Name of the informant: Mr. Mohammed

Relation to the patient: His father

Length of stay with the patient: about his whole life

Reliability of the information: Reliable
3. History of present illness:
Patient's version & Informant's version:
Precipitating factor and Predisposing Factor.
 A Psychological affection after loss of his mother
 B
 C
 D
 E
4. Substance abuse
 Mode of onset: Occasionally
 Effects of symptoms on following:
(Self, cognitive functions, biological functions, social functions, law.) : unknown
 Perpetuating factors: Not mentioned
 Negative history: (History of suicidal threat) :
Not mentioned
 Treatment history: (Nature and duration of present treatment, hospitalization) :
Not mentioned
2
5. Past history: Patient's version & Informant's version:
 Any medical illness: no
 Psychiatric illness: no
 Forensic history: no
had a history of accident and diagnosed with head injury when was adolescent.
6.
Family history:
 Family tree:(3 generation)
 Type of family:
/ Nuclear /
 Family history of illness: (Medical, Psychiatric): His mother was suffering from
schizophrenia and IHD
 Current social status of family: (Communication pattern & relationship with neighbors) :
not
mentioned
7. Personal history:
 Prenatal history :( Planned, Unwanted, Status of pregnancy of mother): not
 Childhood history :( Early childhood, Middle childhood, late childhood): not
 Psychosexual history: not
 Occupational history:
mentioned
mentioned
mentioned
He was a successful doctor
 Marital history: Patient is single
8. Premorbid personality: (Type of person, His strength, Mood, Relationship, Character,
Attitudes and standards, Habits):
 He was normally an outgoing, fun-loving guy. Used to working out, playing his guitar,
and playing football with his friends
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9. INTERPRETATION/ CONCLUSION:
Patient couldn't cope with his mother death and had sad mood ,
withdrawal of daily activities and disturbed sensory affection (auditory
hallucinations)
Witch go along with doctor diagnosis of major depressive disorder
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ROFORMA OF MENTAL STATUS EXAMINATION
1. Consciousness:

Alertness: patient is alert

Awareness: patient is aware
2. General appearance and behavior:

General appearance : good
 Physical health: loss of appetite
 Dressing: good

Attitude towards the examiner: distracted

Comprehension : decreased

Gait and Posture: normal

Psychomotor activity: reduced

Social manner and Non-verbal behavior : patient is irritable

Rapport : poor

Hallucinatory behavior: negative
Tics, Mannerisms, stereotypy
3. Cognition

Attention & Concentration: decreased
 Orientation
Time: oriented
Place : oriented
Person: oriented

Memory
 Immediate memory: intact
 Recent memory: intact
 Remote memory: intact
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4. Judgment:

Social Judgment: impaired

Personal Judgment: impaired

Test Judgment----------------

5. Intelligence:

General information

Calculation

Verbal & Written
(Not affected)
6. Thought & Speech:

Stream: poor/ retarded

Form: abstract thinking

Logical / Illogical – Loosening of association : logical
 Coherent & sequential / goal directed

Possession
 Sense of personal possession :

No
Content of thought
 Preoccupied by the idea of death
 Suicidal ideation

Rate of speech:
slow
6

Reaction time: delay

Volume / tone : low

Quantity : decreased / poor

Involvement in other areas of life: No

7. Mood & Affect:

Quality of mood
 Subjective & Objective: depressed sad mood with flat emotion

Stability :
yes

Reactivity:
No

Persistence:

Quality of affect: undesired

Range --------------

Appropriateness---------------

Mobility --------------

Relatedness ------------------

Intensity of expression : intense

8. Perception:

Illusion:

Hallucination 3 dimensionality : auditory hallucination

Somatic passivity phenomenon:

Depersonalization & De realization:
yes
no
no
no
7

Other abnormal perception:

Body image disturbances (Dysmorphophobia):
no
no
9. Insight: slight awareness of being sick (rating scale 2)
Clinical rating of Insight

Complete denial
1

Slight awareness of being sick
2

Awareness of being sick due to external or physical factors
3

Awareness of being sick due to something unknown in self
4

Intellectual insight
5

True emotional insight
6
Conclusion:
- Mental health examination hence the history and the diagnosis of ineffective coping
with mother death and disturbed perception (auditory hallucination)
-Doctor diagnosis: MDD
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Nurse Process
assessment
Nurse
Diagnosis
1-ineffective
Sub (father):
1-Since the
coping related
death of his
to mother's
mother, Mr.
death as
Abdullah has
evidenced by
been plagued
patient
with symptoms
of sad mood,
sadness,
irritability and
loss of appetite
isolation since
2- he has been
his mother
irritable and
died.
2- Disturbed
Sensory
evidenced by
1-Reduced
the auditory
psychomotor
hallucination
activity
2-disturbed
attention
concentration
1-Patient will
1- Assess the patient’s
demonstrate
Thoughts, beliefs and
improvement
cultural practices in
in handling
terms of how they
and coping
handle their previous
with the
in
and
Implementation
The goal was
and cultural practices
met as
was put in
evidence by:
consideration
1-patient show
improving in
losses.
coping with
the event and
of death at
2- Patient is having new
his own pace. 2- provide situations for
patient to express his
volunteer friends and he
2-The patient
Evaluation
1- patient was assessed
stressor event
feelings and accept them
is spending more time
with them telling his
experience
3- patient has learned
strategies.
using
alternative
ways to deal
with.
2- decrease
coping
Perception as
Obj:
Planning
has to explain as a first step to cope
with the loss
and adopt
detached since
his mother death
Goal
3-Suggest alternative
new ways to deal with
3- Patient
methods to determine
his hurt and
will state that
and cope with
helplessness such as
the voices are
underlying feelings of
asking people to help
no longer
anger, hurt, and
and to express whatever
frequent,
helplessness.
frequency of
the heard
voices
stress events he's
passing through
threatening,
nor do they
3-Aditory
hallucination
interfere with
4- motivate the patient by
his life.
pointing out signs of
positive progress or
change.
5- Help the client to
identify the needs that
4-patient is glad about
his progress and more
determined to get better
5-most of patient's
hallucinations was
9
might underlie the
nothing but an express
hallucination. What other
of his deep needs such
ways can these needs be
as being powerful .
met?
6- Help client to identify
times that the
hallucinations are most
prevalent and
frightening.
6- spend more time
with him when
hallucinations present
and remove any stimuli
that may trigger them.
7- If voices are telling the 7- all precautions are
client to harm self or
taken in case if needed.
others, take necessary
environmental
precautions.
8- Stay with clients when
they are starting to
9- patient is ignoring
hallucinate, and direct
the voices and fighting
them to tell the “voices
them each time these
they hear” to go away.
voices start he tell them
Repeat often in a matter-
to go away
of-fact manner.
9 patient is spending
9- Engage client in
more time with realistic
reality-based activities
people and the
such as card playing,
frequency of the voices
writing, drawing, doing
has decreased
simple arts and crafts or
listening to music.
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