Case work - 1

CASE HISTORY

NAME: - X

AGE: - 21 years

GENDER: - Female

ADDRESS: - Dehradun, Uttarakhand

OCCUPATION: - Student

QUALIFICATION: - Pursuing B.Sc specialisation in human development in childhood studies

MARITAL STATUS: - Single

CHIEF COMPLAINT: -

• Over-weight / Body image issues

• Under-Confident

• Self - Doubt

• Anxiety

• Laziness

• Irritability

HISTORY OF PRESENTING COMPLAINT: -

The Client reported that she needs to lose weight and to improve her body image. Sometimes, she
becomes very lazy and ignorant in her life. She feels that her body image issues will eventually affect
her life which is a big concern for her. She said that she doesn't like parties, hangouts, and all. She
likes to be alone. She has stage phobia .She feels that people always judge her activities. She shares
her personal life with people which harm her sometimes. This attitude of hers has led to irritability
and over thinking sometimes.

MEDICAL HISTORY: - The client is having Migraine and Thyroid. She is in pre-diabetic stage.

PERSONAL HISTORY: - Birth history was found to be Normal. Language and motor
developmental milestones were achieved appropriately. Sleep patterns were normal. Academically,
the client performed well.

FAMILY HISTORY: - The client is having four Family Members including her.

SOCIAL HISTORY: - The client doesn't like to meet new people. She doesn't like meeting friends
often. She's introvert in nature.

CASE HISTORY TAKING - QUESTIONS

Q. Could you please tell me the following: -

• Your Name

• Age

• Gender

• Occupation

• Qualification

• Referral Details

• Cultural Affiliation

Q. Could you tell me your living situation?

Q. Tell me about your Relationship with your parents.

Q. What do you see as being the biggest problem?

Q. What positive changes would you like to see happen in your life?

Q. What would you do if you were asked to lose 30lb?

Q. What is your main concern and fear for the future?

Q. Are you satisfied with the life you have lived so far?

Q. I'm curious to know about your early childhood stage, could we talk?

Q. What's your attitude towards yourself?

Q. Are you overly fatigued or tired at the end of the day? How about at the end of the week?

Q. Have you been experiencing significant mood swings, crying, or thoughts of suicide?

MENTAL STATUS EXAMINATION

• APPEARANCE AND BEHAVIOUR: Neatly dressed and well groomed. Conscious about her
Dressing Sense. Rapport was well established. The client was relaxed and comfortable while
speaking. She maintained eye contact and sat upright throughout the session. She was very
cooperative, attentive, and willing to talk.
• PSYCHOMOTOR ACTIVITY: Appropriate motor activity.
• SPEECH: The client had a normal tone of speech.
• MOOD AND AFFECT: Appropriate but sometimes there's mood swings.
• COGNITIVE FUNCTIONS: Normal. She was conscious and attentive. She had well
established memory.
• ATTENTION AND CONCENTRATION: Normal.
• ORIENTATION: Well oriented.
• THOUGHT PROCESS: Logical thought process.
• THOUGHT CONTENT: The client listed her concerns very clearly.
• INSIGHT: Very much Aware about her problems.
• JUDGEMENT: Appropriate. She was very much aware about what needs to be done and how
her decisions will affect her and her family members for the better.

Questions on Mental health Examination -

• COGNITION: -

Q. What's the Date today?

Q. What was your last full Meal?

Q. Where do you attend your classes?

• ATTENTION: -

Q. Repeat the alphabets after me (both upwards and downwards)

-B
H
N
Q. What's the time by your watch?

• MEMORY: -

1. Immediate

Q. Look and tell me the name of at least three things around you

Q. What's the colour of your bag you have in your hand

2. Recent

Q. Which mode of transport you used today to come here?

Q. Did you buy ticket?

3. Remote

Q. When is your Mother's Birthday?

Q. Did you celebrate your birthday last year?

• INTELLIGENCE

Q. Who's our education minister?

Q. What comes after alphabet D?

Q. Which scheme/Yojana does Modi ji run recently?

• ABSTRACT ABILITY

Q. What's the difference between vegan and vegetarian?

Q. What's the similarity between photosynthesis and respiration?

• JUDGEMENT

Q. What will you do if you see a puppy crossing the road with moving vehicles?

Q. What will you do if your brother got hurt by knife?

Q. What will you do if you get stuck in an elevator?

• INSIGHT

Q. Do you think you are a patient person?

Q. Do you think your Decisions are always right?