CASE HISTORY PROCEDURE

Socio-Demographic Data
Name: V.K
Age: 45
Sex: Male
Occupation: military Officer
Marital status : un married
Mother Tongue: Tamil Marital
Religion: Hindu

Education: Diploma

Family: Single

Birth Order: Second Child

Socio-economic status: Lower middle class

Referral: Sister

Mode of Therapy: Behavioral therapy

Health problem: Heart bypass operation alone

Informants
Source of information: Patient

Complaints
• manic-depressive illness
• Abnormally upbeat, jumpy or wired
• Increased activity, energy or agitation
• Exaggerated sense of well-being and self- confidence (euphoria)
• Decreased need for sleep
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Poor decision-making

Co-occurring conditions
1- Anxiety disorders

2- Eating disorders

3- Physical health problems, such as heart disease, thyroid problems, headaches or obesity

History of Present Illness

Patient complained of atypical features of depressive episodes, chronicity of symptoms,
psychomotor agitation, hypomania like symptoms, not being able to express himself , being
incapable of social interaction with others.

Onset:
First episode of illness appeared during adolescence, with social phobia symptoms and was
afraid of disgracing himself, felt unhappy.

Precipitating factors:
Symptoms increased when he left for college, and he only had a limited relationship with others.
He felt more distressed in crowded places such as the classroom, dining hall, or library. She felt
that he was worthless, had no motivation, and lacked energy.
Course of the illness:
Patient not completely remitting despite a 5-year-long psychiatric treatment.

Continuous illness:
Depressive episodes, lack of volition, thoughts of worthlessness, persisted anorexia, irritable
and tense for no apparent reason from time to time, lack of concentration, urge to move around
restlessly.

Associated disturbances:
Mood swings, personality disorder, dysthymia

Family History
Family history of illness: There is no family history of any major physical/psychiatric illness or
substance abuse except one paternal aunty died of tuberculosis (TB).

Personal history:
Birth and early development: It w normal delivery out of non-consanguine m prenatal, natal or
postnatal complications. delay in developmental milestones.
Behavior during childhood: Patient did not have any unusual behaviour or conduct disorder.
Educational History: Patient was good in studies although he had some adjustment problems