HISTORY AND BIODATA OF THE PATIENT

1.IDENTIFICATION DATA

Name : Mr. Kishor Ahirwar

Age : 23 years

Sex : Male

Father : Mr. Ravi Ahirwar

Education : B.E

Marital status : Unmarried

Occupation : Student

Religion : Hindu

Address : House No- 121,nehru nagar, Devas

Informant : Patient’s Father

Information : The information is reliable and adequate

2.PRESENTING CHIEF COMPLAINTS :

As per the patient :

 Feeling helpness
 Not able to take decision
 Feeling that not able to survive
 Feeling guilty
 Thinking about suicide
 Getting early in morning (2-3am)
 Fatigue
 No intrest to do work
 Feeling irritation while someone disturbing
  Not feeling hungry

According to informant

 Not taking food properly

 Not talking bath regularly
 Not talking eith others
 Attempt suicide by handing
 Not having interest to do work or going outside
 Complaining about body pain

3. HISTORY OF PRESENT ILLNESS

Mr. Kishor is a student of final year B.E. He was apparently normal before six month. He got fail
marks in his final examination. Since that time he was not behave normal. He was not interesting
to do work or go to college. He was not taking proper food. He was having continuous feeling of
hopelessness and getting early in morning. Before 15 days he attempt suicide by hanging could
not succeed because his elder brother seen. On 25/10/2018 he was admitted in Bhopal memorial
hospital and diagnosed as severe depression and admitted in male close ward for further
evaluation and treatment..

4. PAST PSYCHIATRIC AND MEDICAL HISTORY

Mr. Kishore is not having any significant past psychiatric history

5. FAMILY HISTORY

Male

Female

Patient
S.NO Name of Age/sex Relation Education Occupation Health
family with status
members patient
1. Mr. Ravi 51y/Male Father 8th std Business Healthy
2. Ms. Saroja 48y/Female Mother Illiterate Housewife Healthy
3. Mr. Ramesh 27y/Male Brother B.E Teacher Healthy

PERSONAL HISTORY

A. Perinatal history
Mr. Kishore was delivered as full term normal vaginal delivery. He cried immediately
after birth and there was no postnatal complication like cyanosis, convulsions and
jaundice.

B. Childhood history
 The primary caregiver was the patient’s mother
 Feeding and weaning were appropriately done.
 Developmental milestones were achieved at appropriate age.

C. Educational history
 Age at beginning of formal education: 5 years
 Academic performance: Below average
 School phobia: No

D. Play history
 He used to play with both sex peer grou and had good relationship with peers.

E. Emotional problem during adolescence

 There is no significant history of emotional problems like running away from home,
aggressiveness and assault.
 F. Puberty
Secondary sexual characteristics apeared at the ageof 14 years. He did not have anxious
mood regarding sexual changes.

G. Occupational history
 Patient is a student. He is performing well in study. He is introvert and having less
number of friends.

H. Premorbid personality
 Patient had problems with her brother. Till now, she doesn’t talk to her brothers.
 He used to stitch clothes during her leisure time.
 The eating pattern, elimination and sleep patterns were normal.
 Patient does not use any drugs, tobacco or alcohol..
 Patient has no medical problems.

PAST MEDICAL AND SURGICAL HISTORY

No history of any communicable diseases and no history of any surgery in the past.
GENERAL EXAMINATION

Vital Signs

Temperature : 36.2 degree celsius

Pulse : 76 beats/minute

Respiration : 28 breaths/minute

Blood Pressure : 120/80 mm of Hg

1. CARDIOVASCULAR SYSTEM AND PERIPHERAL PULSATIONS

INSPECTION

No lifts or heaves

PALPATION

No palpable pulsation over the aortic pulmonic and mitral valves. Apical pulsation can be felt.

PERCUSSION

No cardiac dullness found.

AUSCULTATION

S1 and S2 can be heard, no abnormal heard sounds, Cardiac rate is 76 bpm.

PERIPHERAL PULSATIONS

Peripheral pulsations can be felt

2. RESPIRATORY SYSTEM

INSPECTION

The shape is elliptical, moves symmetrically, no chest retractions found, no scoliosis / kyphosis /
lordosis seen.
PALPATION

No lumps or masses found no areas of tenderness seen. Tactile fremitus checked no evidence of
consolidation, obstructions of thickening of the pleura.

PERCUSSION

No abnormal sounds like hyper resonance, resonance is found

AUSCULTATION

No abnormal lung sounds found like wheezes, crackles.

3. ABDOMEN

INSPECTION

Skin color is uniform, no lesions, no pigmentation, and no scars.

AUSCULTATION

Hypoactive sounds found

PERCUSSION

No dullness is found

PERCUSSION FOR LIVER

No dullness is found

RENAL PERCUSSION

Normal

PALPATION

No tenderness or masses present.

 4. MUSCULOSKELETAL SYSTEM

Posture of the patient is straight gait is normal.

RANGE OF MOTION

Range of motion of neck, spine, upper and lower extremities, joints is possible in the patient

5. LYMPH NODES

No inflammation or swollen lymph nodes found

6. PELVIC EXAMINATION

Patient have no discharges per vaginally, no redness, no signs of infection present.

7. OTHERS SIGNS

No other signs found

MENTAL STATUS EXAMINATION

A.GENERAL APPEARANCE AND BEHAVIOR

Appearance: Looks accordingly her age

Facial expression : Blunted

Level of grooming : Normally dressed.

Level of consciousness : Patient is fully conscious and alert

Mode of entry : Patient was brought by persuasion.

Behavior : Normal

Cooperativeness : Patient is adequately cooperative

Eye- to –eye contact : Eye contact is easily maintained

Psychomotor activity : Psychomotor activity is normal.

Rapport : Spontaneously established

Gesturing : Normal

Posturing : No stereotypic movements or catatonia

Hallucinatory behavior :No

B.SPEECH

Initiation : Speaks when spoken to

Reaction time : Normal

Rate : Normal rate of speech

Productivity : Elaborate replies

Volume : Normal

Tone : Normal variations are present

Relevance : Sometimes off target

Stream : There is no circumstantiality or tangentiality

C. MOOD AND AFFECT

Subjective : Patient says that she is happy and is feeling good.

Objective :Patient looks cheerful when spoken but remains blunt when silent.

Appropriateness : Affect is appropriate.

D. THOUGHT

Stream: the flow of thought is normal

Form: Normal, there is no tangentiality or circumstantiality

Content: Patient does not have any delusions. Patient has episodes of panic anxiety, periodically
which exists for 15-20 minutes.

E.PERCEPTION

No perceptual abnormality present.

F. COGNITIVE FUNCTION

Consciousness : Conscious

Orientation, attention, concentration, memory, intelligence, abstraction, judgment etc could not
be elicited because patient does not respond. Patient continues to lie down in the bed.

G. INSIGHT

Patient completely denies his illness.