1.
IDENTIFICATION DATA
1.1 Name : XYZ
1.2 Age : 32 years
1.3 Sex : female
1.4 Education : no
1.5 Occupation : no
1.6 Income : -
1.7 Present Address : -
1.8 Permanent Address : -
1.9 Religion : Hindu
1.10 Caste : Xyz
1.11 Language : Hindi
1.12 Marital Status : married
1.13 Duration of Problem : 15 days
2. INFORMANTS
2.1 Name : XYZ
2.2 Relation with the patient : nephew
2.3 Period of acquaintance : 22 years
2.4 Reliability : Not reliable
3. CASE HISTORY
3.1 Chief Complaints (According to the patient) :
3.2 Narrative History
The patient was a 32 year old lady whose height was 4.10 inches and her weight
was 30 kg. She had dusky complexion. She was very thin and appeared weak. she
was a married lady and had three children.
Patient told that she feels lonely; she thinks that she is isolated from others. she
wants that everyone should live with her. She cannot live alone. on enquiring
further. Patient told that she had problem since 2009,September.at that time she
used to abuse people. Patient complaint that she sees those people who are dead.
her mother-in-law is dead. Still she sees her and talk with her. She used to beat
anyone she saw around. She forgot her family members including her children
and husband.then her fmily reffered her to the doctor at mental hospital.within a
month she got relieved with the medicines and then she stopped them.this was the
reason her problem relapsed.
At present,she feels very lathergic and restless. She doesnot want to do any work,
she does not want to cook food and nor likes to eat it.she also does nat brooms har
house. Earlier she used to sit at her father-in-law’s shop but it depends on her
mood if shr likes to sit then she sits and if she does not likes then she does not
sits. She only wants to talk with the people and everyone should live with her.
Now the other family members are blaming her. Her husband’s aunt talks to her
in abusive language and blames her her that she is not a good
3.3 Personal History
a. Infancy
Patient’s infancy information is absent.
b. Childhood
Patient didn’t know about his childhood.
c. Adolescence
Patient got married in her adolescence.
d. Educational History
Patient’s told that she is uneducated.
3.4 Premorbid Personality (PMP)
a. Interpersonal history
Patient’s relationship with family was good earlier but now it is not good.
b. Use of Leisure time :
Patient didn’t use her leisure time.she said that she has no hobby.
c. Predominant Mood
earlier she used to stay happy,but now she feels despaired and
lethargic.
d. Attitude towards self
Patient’s attitude toward self was good before his problem but his attitude
toward self was not good since problem.
e. Attitude towards work and responsibility
Patient’s attitude toward self was good before his problem but his attitude
toward self was not good since problem.
e. Religious belief and Moral Attitude
Patient did not believed in God.
f. Fantasy Life
Patient’s fantasy life was absent.
g. Habit
Patient had no such habit.
3.5 School & Occupational history
Patient didn’t went to school.she is uneducated.
3.6 Treatment History
Patient had taken treatment from mental hospital barielly.
3.7 Family History
Patient family nobodt had any kind of mental problem.
a. Family Treatment:
b. Genetic Diagram
Male
Female
Patient
c. Family Description
S.No. Member of Patient’s Family Age Psychiatric Medical Illness
1. Father Not Available Not Available
2. Mother Not Available Not Available
3. Brother Not Available Not Available
4. Sister Not Available Not Available
3.8 Home & Social Environment
Patient’s home and social environment information is good; family tries and
cooperate with her.
4. MENTAL STATUS EXAMINATION
4.1 General Appearance
Patient’s height was 4.9 inches and his weight was 30 kg. Patient’s clothes
were dirty but his clothes were according to weather attitude.
4.2 Attitude Towards Examiner
Patient’s attitude was cooperative toward examiner.
4.3 Motor Behavior
Patient’s motor behavior was normal.
4.4 Posture
Patient’s posture was normal.
4.5 Gait
Patient’s way of walking was normal.
4.6 Facial Expression
Patient was happy while talking to the examiner. She told that she loved
talking with the examiner.
4.7 Voice & Speech
a. Rate & Quantity of Speech
Patient’s speech was present.she was spontaneous. her
productivity of speech was normal.rate was even normal.whatever questioned were asked
she gave required information.
b. Volume & Tone of Speech
Patient’s volume and tone of speech was increased.
c. Flow & Rhythm of Speech
Patient was smooth.she answered all the questions without
hesitation.
and he had thought blocking because examiner forced him to gave
responses.
4.8 Emotional Reaction (Mood & Affect)
Patient was looking sad and despaired.
4.9 Thought
a. Thought Process
Patient had illogical thinking. When examiner asked any question
to the patient he gave illogical responses.
b. Stream of thought
Patient had flight of ideas and thought block. Because patient’s
responses were not communicate with each other and patient’s
thought were blocking and examiner forced him to give responses.
c. Contact of thought
d. Abstract Thinking
Patient’s abstract thinking was present because he knew the
differences between table & chair, eye & ear and lion & dog.
4.10 Phobia
Patient didn’t has nay type of phobia.
4.11 Perceptual Disorder
Patient didn’t has nay type of perceptual disorder.
4.12 Orientation
a. Time
Patient didn’t know about the time.
b. Place
Patient didn’t know about the place.
c. Person
Patient said that the informant was his brother whereas the
informant was his boss.
4.13 Attention & Concentration
Patient’s digit repetition was good and his concentration of counting and
days of week was good.
4.14 Memory
a. Immediate Memory
Patient’s immediate memory was present because he knew digit
span, digit backward and digit forward.
b. Recent Memory
Patient’s recent memory was not present because he didn’t know
about his last day or night.
c. Remote Memory
Patient’s remote memory was present because he knew his age, he
was born and when he started his work.
4.15 Intelligence
Patient knew the C.M. of U.P.
4.16 Judgment
Patient’s judgment ability was present because when the examiner gave
him a situation of burning house, he gave right response.
4.17 Insight
Patient had no insight.
4.18 Psychological Examination
Patient had no physical examination.
4.19 Psychological Assessment
Rorschach test had done on patient.
4.20 Educational Examination
Education examination was not done.
4.21 Summary of Diagnostics Formulation
a. Patient was sad.
b. Depressed
c. Stable
d. Despaired
e. Incoherent
f. He connected each and everything with God.
g. He didn’t do eye to eye contact with examiner.
4.22 Provisional Diagnosis
Axis –I - Alcohol Abuse
Axis –II - None
Axis –III - None
Axis –IV - None
Axis –V - GAF 35
4.23 Investigation Plan
a. Investigation
There is need to talk to patient’s family
b. Treatment Plan
Psychoanalytic Therapy is suitable.
4.24 Details of Enclosure
