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Family tree:- index:-

- Expired
-Patient

[Father] [Mother]

[Patient] [Wife]

[son] [Daughter]
Mental Status Examination:-
 Appearance:-
Body Build- Endomorphic

Height- 6’2”, Weight- 78kg

Look- Comfortable

Self care- Maintained

Grooming- Normal

Cloths- Appropriate and Tidy

 Behaviour:-
Facial Expression- Pt is looking Sad.

Eye Contact - Maintained and Intermittent.

Patient having ability to follow command.

Psycho motor activity- Normal

Posturing - Normal posture.

 Attitude:-
Patient having positive and co-operative attitude towards observer.

 Level of Consciousness:-
Patient is alert but lethargic.

 Orientation:-
1. Question(Nurse): What is your full name?
Answer( pt): Sanjeeb kumar Pyne.

2. Question(Nurse): What is the time now?

Answer( pt): 11.35am

3. Question( Nurse): Where are you now?

Answer(pt): SUM hospital

REMARK: Patient is fully oriented.

 Speech and Language:-


1) Quantity: Spontaneous
2) Rate: Normal
3) Volume: Soft
4) Fluency and Rhtym: Cleard
5) Relevance: Fully relevant

 Mood:-
Question(Nurse): How are feeling now?

Answer( Pt): I am fine.

 Affect:-
Question(N): How are you feeling?

Answer(pt): I am fine.

Objective(Nurse): Depressive

Remark:- Patient having incongruent mood, but appropriateness in situation.

 Thought Process:-
Question(N): Are you worried/ scared about something?

Answer(pt): No not now, it was present earlier.

Remark:- Patient’s flow of thought is normal, goal directed. No thought block or any kind of
tangentiality there.

 Thought Content:-
Question(N): Do you find yourself ruminating about things?

Answer(pt): No, no such things.

Question(N): Do you ever feel detached from anyone around you?

Answer(pt): No

Remark :- Patient having no delusional thought content, no phobias or any preoccupations in present.
 Attention:-
Question(N): Repeat the digit 10 forward and back ward .

Answer(pt): Forward- 11, Backward- 9

Remark:- Normaly aroused.

 Concentration:-
Question: Count 1-20 rapidly.

Answer(pt): Correctly count.

Remark: Patient’s concentration is intact.

 Memory:-
A. Immidiate Memory:

Question: Which number you have recently count?

Answer: 1-20

B. Recent Memory:

Question: What you have taken in break fast?

Answer: Idli and Curry.

C. Remote Memory:

Question: Where did you get married?

Answer: At Baripada.

REMARK: Patient’s Immidiate, Recent and remote memory is intact.

 Intelligence:-
Question: Solve 2+3+8

Answer: 13

Remark: Patient’s intelligence power is intact.

 Judgement:-
Question: What is your future Plan?

Answer: No plan yet.

Remark: Patient’s Judgement is impaired.

 Insight:
Patient having Grade 4 insight scale. He having awareness of being sick but due to some thing
unknown in himself.
Physical Examination:-
I. Mouth and Pharynx
 Lips: Dry
 Odour of mouth: no bad smell
 Teeth: Clean
 Tongue: clean
 Gum: Normal, no bleeding
II. Neck and Chest
 Lymph nodes: No enlargement
 Thyroid gland: Normal
 Thorax: Normal shape and symmetrically expand.
 Heart sound: no murmur sound.
 Breath sound: no wheezing sound
III. Head and Face:
 Scalp: clean, no dandruff
 Hair: black and clean
 Face confused
IV. Skin and Texture:
 Colour: Fair
 Texture: dry
 Temperature: warm(990F)
 Lesions: no
V. Abdomen:
 Observation: no skin rashes present
 Auscultation: normal bowel sound present.
 Palpation: No presence of gas and fluid.
 Percussion: Normal tenderness present.
VI. Extremities:
 Upper extremities: Movable
 Lower extremities: Movable
 Back: no back pain issues.
VII. Genital and Rectum:
 Genital area: Clean
 Rectum: No issues of piles or fissure.
 Urethra: Normal
 Prostate: Normal
VIII. Neurological Tests:
 Co- ordination Test: Poor
 Reflexes: Good
 Equilibrium Sensation: Normal

Pre-ECT Care check lists:-


 Consent taken
 Assessed Vital Signs. ( B.P- 110/80mm-Hg, Pulse-86/min, Temp- 99 0F)
 Nil by mouth(6-8 hour)
 Head shampooing.
 Removed jewellery, dentures, contact lense etc.
 Advice to empty bladder and bowel just before ECT.
 Gave Pre-Ect medications- Inj. Propofol 2mg/kg bdw. I.V

Inj. Glycopyrolate (0.6mg).I.V

Inj. Scolin(25-30mg).IV

Inj. Loxicard 2% I.V

During ECT Care:-


 Placed the patient on ECT table.
 Stayed with the patient
 Placed mouth gag.
 Apply Gel and electrodes.
 Monitored voltage intensity and duration of electric activity.
 Monitored Seizure activity (Tonic-Clonic seizure)
 Monitored Vitals.

Post-ECT Care:-
 Placed patient in side line position.
 Monitored vital signs. ( B.P- 130/70mm-Hg, Pulse- 86/min, Temp- 99.2 0F)
 Administerd Oxygen.
 Assessed for postical confusion.
 Reoriented the patient after recovery.
 Recorded the procedure.

DATE NO.OF ECT DURATION AMMOUNT TYPE OF SEIZURE


TAKEN OF CURRENT
IN VOLT

08.11.2019 1st 30sec 78 J GTCS

11.11.2019 2nd 24 sec 61 J GTCS

13.11.2019 3rd 25sec 88 J GTCS

15.11.2019 4th 24 sec 61 J GTCS

18.11.2019 5th 22 sec 65 J GTCS


SUMMERY:-
Patient Mr. Sanjeeb admitted in Male Psychiatric Ward at SUM
Hospital, already taken 5th number of ECT. Before ECT pre care given to him and during
ECT also vitals monitored, it was stable. After ECT Post care also given to him,
comfortable positioning given and again checked Vitals also. It was stable. There were no
Postical confusion, the patient reoriented after recovery. All the procedure was recorded
with date and time. Patient was feeling better now.

IDENTIFICATION DATA:-
Name of the patient:- Sanjeeb Kumar Pyne

Age:- 35 year

Sex:- Male

Religion:- Hindu

IP NO- 191026165

Marital Status:- Married

Education:- B.A Pass

Occupation:- Driver

Address:- Baripada, Mayurvanj

Informant:- Mother of patient.

 Presenting Chief Complain:-


According to Patient,” Mate nido hauni ni, Kicchi bi vala laguni, Khali munda bulauchhi, Voko bi hau
ni”.

According to informant,” Se 10 din hela ratre jama sou ni, Sabu bele chid chid hauchhi, kichhi
khau ni, ragi jauchhi”.

 History of Present Illness:-


Patient was apparently alright before 1 month back, when he took Corrosive Poison at 24.10.19 at 2
pm. At that time he was admitted to SUM Hospital at 25.10.19 for further treatment.

 Treatment History:-
Patient was apparently alright 1 month back then after few days his father expired, he was very
much depended upon his father, So he couldn’t bare that pain and started feeling lonely and
depressive. Therefore he took corrosive poison at 24.10.19 at 2 pm. Soon he admitted at SUM
Hospital and shifted to Ward-21 for treatment. After that on day 26.10.19 he found with the
complain of severe irritability, insomnia, mood disturbances etc so he was shifted to Male Psychiatric
Ward from Ward-21 for further treatment.

 Past Psychiatric or Medical History:-


No such history of psychiatric and medical illness.

 Family History:-
There are 5 members including patient in family.
REPORT WRITTING
ON
ELECTRO CONVULSIVE
THERAPY

[IMS & SUM HOSPITAL, S’O’A UNIVERSITY,


BHUBANESWAR]

SUBMITTED TO-
SUBMITTED BY- MS.SUCHISMITA PAHANTASINGH
RAKESH RATH

ASSO. PROFFESOR M.SC


NURSING 1ST YEAR
[SUM NURSING COLLEGE]

SUBMITTED ON-
2ND DECEMBER 2019