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Summary of the Case

Main topics of the discussion
Client’s basic information, presenting complaints, assessment tools, diagnosis, proposed
mangement plan. (write in paragraph)
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Identifying Data
Client’s name: Saba
Age:18
Gender: Female
Education:
Number of siblings:3
Birth order:2
Marital status: student
No of sessions:
Date seen:
Last date seen:
Reason for referral
The patient was referred for further medical investigation, as she was demonstrating sihns
suggessive of a psychiatric disorder. The patient was diagnosed with CP(Cerebal palsy).
She have difficulty in communication. She also have cognitive problem, she have low
memory. She can’t recognize things. She is also physically unhealthy and have some
motor skills problem.

Presenting Complaints:

Symptoms Duration
High grade fever At the age of 15 days
Fits Last fits in 2013
muscles stretch Before 2 years
Physical and language Initial development
milestone
Poor Motor skills Initial development

Initial Observation
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Sara is cheerful and social child. Sara is 18 yrs old. She have poor motor skills and have a

CP(Cerebal Palsy). Due to this she have a poor memory and weak muscles. Sara’s speech

is not clear. She have a problem with speaking and communication. Her eye contact is

poor.While talking she become loud. She does not tell anyone when she is hungry. She

eats when someone else give food to her. She has aggressive behavior in her home. She

usually fight with her siblings at home. Sara is very possessive about her things. She also

understand the command and obey her teacher.

Developmental History of the Problem

Birth weight: 3.5kg
Smiling: After 8 months
Head control: After 1 year
Recognizing: After 1 year
Babbling and Teething: 9 months
Sitting: After 1 year
Walk alone: After 3.5 year
First word: After 5 year
Able to feed alone: After 1 year
Urine control: After 4 year
Puberty
Behavior problem
a. Restless or hyperactive: yes
b. Tamper tantrum
c. Hitting other or self: hits if interrupted
d. Aggressive: yes
e. Submissive
f. Others
g. Head banging: No
Physical defect: Accident with motorbike
Failure in studies
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Learning problem
a. Reading
b. Writing
Any other

Background Information
Personal history
Birth:
Client was born in 2003 through a normal birth. She had no history of pain. She was
healthy child. She never faced any accident in her life.

Developmental milestones history

Client didn’t report any developmental milestone history.

Early childhood
She spend her early childhood with her parents.

Educational history

Sara started her schooling at the age of 9 years in special school. she liked to go to school
and a good student. She had lack of interest in sports. She take part in different activities
in classroom. She had a good relationship with her friends and teachers.

Occupational history
Sara have no occupational history

Social history

had jolly and friendly nature before her illness and she had unhealthy and not strong
relationship with people. She had no broad social circle. She was extrovert and had
sharing nature but now she felt sad and lonely and not like to meet and talk with others so
she was unable to enjoy properly the company of friends and other relatives due to her
illness.

Sexual history
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The client reached puberty at the age of 10 years. She got sexual awareness.

Marital history
She had no marital history.

Drug history
Sara have no drug history

Forensic history
The client never commits any crime and don’t have criminal history in past.

Premorbid personality

Sara belongs from a poor family and his parents are doing job. Her parents sre not too
much coporative. Sometimes her parents give punishment by beating her and give reward
by . she had a good relationship with her parents.

Family History

History of Psychiatry/ Medical Illness

Provisional Formulation.
Assessment
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Formal Assessment

House test

Informal assessment

Clinical interview

Subjective rating

Reinforcement

Diagnosis

Prognosis

Recommendation

Management plan

Activity
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Reference