Clinical Case Report

(____ _____)

Safeen Raza
BSAPE-20-51
BS Applied Psychology Session
2020-24

Department of Applied Psychology

BAHAUDDIN ZAKARIYA UNIVERSTY, MULTAN

 Clinical Case Report

APPROVED BY:

_______________________

CHAIR PERSON:

_______________________

SUPERVISOR:

_______________________
Acknowledgement:

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Student Name

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 Dedication

Dedicating to my loving Parents, Colleagues, Class fellows, internees and all those who helped me in
completing this Internship.

Certificate

It is certified that this Internship Report of History Taking, Informal and Formal Assessment of five
Patients with the duration of 6 Weeks is solely presented by _______________________ has been approved
for submission to Department of Applied Psychology, Bahauddin Zakariya University, Multan.

Internship Supervisor/Head of Psychiatry Department

______________Signature________________

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 Table of Content
Case 01………………………………………………………………..01

Case 02………………………………………………………………..##

Case 03………………………………………………………………..##

Case 04………………………………………………………………..##

Case 05………………………………………………………………..##

Appendix………………………………………………………………..##

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 Case I
Disorder

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Information Identifying:
My patient Pervaiz is 43 years old, a resident of Multan. He is married, uneducated and
unemployed.
Mode of Referral:
The patient came in general OPD.
Presenting Complaint:
My patient came in with a complaint of seeing and hearing a bunch of Hindus, Christians and jews who are
trying to kill him. They don’t let him sleep. And because of that. He is becoming agitated and angry.
History of Presenting Illness:
My patient has complained of seeing and hearing people since 2007. He says that they are Hindus, Christians
and Jews who are after him. They disturb his sleep, spoil his food, spoil his body. He says that they don’t let
him stay clean. They like it dirty, and they’ve made him dirty. The patient has constant tremors in his body
but mostly his hands, that are very shaky. The patient is worried about his cleanliness. He is experiencing
fearfulness, hearing voices, reduced sleep, suspiciousness and ager outbursts for almost 10 years. He is
worried that those people will make his kidneys and heart fail and that they squeeze his ribs. He is also
afraid that they’ll kill him just like they killed his uncle. Patient also believes that his wife is unfaithful and
that his kids are not his, and that they belong to someone else as he is suspicious that his wife has extra-
marital affairs. He also believes that his wife is an illegitimate daughter herself. He claims to have divorced
his wife because the voices told him to do so. The patient also has suicidal thoughts, and he hasn’t worked in
4 years. He thinks those people are terrorists and went police and media to inform them, but they didn’t
listen.
The voices are commanding in nature, and they haven’t let him pray in 3 years. He also thinks that they’ve
planted a chip inside him. And they are going to kill him or ask him to kill himself. Although, he’s never
tried to act on suicidal impulses. Patient also has blasphemous thoughts regarding his religion.
Personal History:
Patient is uneducated and the father of 3 sons. He used to work as a laborer but hasn’t worked in 4 years. His
sister and brother in=law manages the finances of his family. Or someone else gives him some money. He
believes that his sons are not his own because they don’t resemble him. And he meets them out of shame and
embarrassment of society. He is also not talking to his wife as he believes that she is unfaithful and
illegitimate herself. According to him, he has divorced his wife. But they are still living together, and his
attendant says that he hasn’t divorced her.

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Family History:
The parents of the patient are dead. He has 3 siblings. But he did not provide much information about his
relationship with them. His sister is taking care of him and his family. He is not in a condition to maintain a
good relationship with anyone. No one else in his family has such an illness.
Treatment:
He is getting his spiritual treatment done in Masjid by Zikr-o-Azkaar. As for the medical treatment, the
patient has a history of taking 2 oral injections, and antipsychotics but the record is unavailable. His body
was shaking which was a side effect of medicines he’d been using.
Past Medical History:
Patient has been taking anti-psychotics, and oral injections.
Past Surgical History:
Unremarkable.
Past Psychiatric History:
The patient has been being treated by various doctors for the same illness.
Past Forensic History:
Unremarkable.
Substance Use:
Patient takes cigarette and Niswar.
Pre-Morbid History:
My patient led a normal life before his illness started and he used to go to work and earn. His mood was
much better. He also had a good relationship with family. His leisure activities included going out, having
gatherings of relatives and friends.

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 PSYCHOLOGICAL ASSESSMENT
1. Informal Assessment
2. Formal Assessment

Informal Assessment
Mental Status Examination:
Appearance:
The patient was in a neglected state. His hygiene was severely compromised. His clothes were not clean. His
body was visibly dirty, and his appearance was disheveled.
Thought Process:
His train of thoughts was inconsistent, The content of his thoughts was those Hindus, Christians and Jews.
Mood:
His mood was unpleasant. He was getting agitated even by sitting and explaining his situation.
Speech:
His speech was incoherent, fast, indecipherable at some point and he had trouble keeping up with one
thought as he kept changing his verdict and repeating most of the things he was saying. At one point he
stopped talking and lost his focus as if he was listening to something else.
Insight:
Insight was absent. He was fully convinced that everything he’s hearing and seeing are completely true.
Cognition:
His cognition was impaired. He was forgetting things and had trouble making coherent sentences.
Perception:
The patient has impaired perception. He has:
Auditory Hallucinations
Visual hallucinations
Delusion of control
Delusion of infidelity
Paranoid Delusion.
Formal Assessment
(___Test Applied_____)
(Result and scoring) Conclusion:
(___Test Applied_____)
(Result and scoring) Conclusion:

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Diagnosed Disorder
My patient is diagnosed with Schizophrenia.

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 Case-II
(Disorder)

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Information Identifying:
Shaista, an 18-year-old woman, lives with her husband in Kot Addu. She studied till 5 th Grade. She is
married.
Mode of Referral:
She was admitted through OPD 1 day ago.
Presenting Complaint:
Shaista, reports experiencing chest and pain in flank region while her eyes become blurry, loses her balance
and episodic loss of consciousness.
History of Presenting Illness:
My patient was in usual state of health when she started experiencing her symptoms 8 months ago. A few
weeks after she got married. According to her mother. She is having blurry vision, pain in the flank region,
body aches, and constant headache that extends to her neck. She gets dizzy spells and faints. She
experiences fits when gets stressed about something her mother-in-law said or over work. Her eyes shut
down and she gets dizzy and falls. A fit lasts for half an hour and after she gets her bearings, she doesn’t
remember how it happened. A few weeks after marriage, she set her clothes on fire and her family is now
aware of her. Patient has some depressive symptoms too as she is usually in a low mood and doesn’t want to
socialize with anyone. Patient has a poor appetite. She was frail before marriage and now she is much
weaker as she doesn’t have energy. The quality and quantity of sleep is fine.
Personal History:
Shaista is a married woman. She studied till 5 th Grade and got married at the age of 17. She is a housewife
and has good relations with her husband, but not with anyone else as she said that she doesn’t like her in-
laws. She used to live in a city and her in-law's house in a village, and she doesn’t like the change that comes
with it. She doesn’t like to work or being asked to do it. She also feels inferior to her in-laws as they are
educated, and she is not. She also sleeps most of the day. Her in-laws and mother are reinforcing her
behavior by telling everyone that she is not fine.
Family History:
Shaista is the eldest of 4 siblings. She has 2 sisters and 1 brother. Her relationship with her parents and
siblings is good. They are good at communicating with each other. She is overprotected by her mother and
her behavior is being reinforced by her family. No other person in her family has any medical or psychiatric
history
Past Medical History:

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She was admitted in MediCare because of the same illness, and she was unconscious for 72 hours (about 3
days).

Past Surgical History:

Unremarkable.
Past Psychiatric History:
Unremarkable.
Past Forensic History:
Unremarkable.
Pre-Morbid History:
Before the onset of illness, my patient used to be in a good
mood. She liked to socialize with family and other
relatives.She had good relations with everyone and was an
extrovert by nature.

PSYCHOLOGICAL ASSESSMENT
1.Informal Assessment
2.Formal Assessment

Informal Assessment
Mental Status Examination:
Appearance:
The patient’s overall appearance was fine. She looked clean and well-kept. Her hygiene was also good.
Behavior:
My patient’s behavior was less cooperative at the beginning. She did not want to talk much. Her face was
blunt. Her grooming was okay.
Speech:
Her speech was fine, and it was coherent as she explained her symptoms well. But her voice was very low,
and it was difficult to hear her.
Mood:
My patient was euthymic.
Thought Process:
The content of my patient’s thoughts was her dislike of her new environment. As she kept mentioning things
that she does not like.

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Cognition:
My patient memory seemed fine as she had no trouble remembering things.

Perception:
My patient had an insight into her illness. She was aware of her symptoms, and she was disturbed due to her
condition.

Formal Assessment
(___Test Applied_____)
(Result and scoring) Conclusion:
(___Test Applied_____)
(Result and scoring) Conclusion:

Diagnosed Disorder:
According to patient’s history and MSE, the patient possibly has
1) Dissociative Disorder
2) Adjustment Disorder

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Case III

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Information Identifying:
Rukhsana Kausar, 30 years old married woman with two daughters lives with her husband. She is a
housewife and resident of Rahim Yar Khan.
Mode of Referral:
She was admitted through OPD, on 15th June 2023
Presenting Complaint:
Rukhsana, reports experiencing intrusive thoughts and engaging in repetitive behaviors or actions,
forgetfulness, negative thoughts, weeping spells, stress, agitation, self-harming thoughts, extreme
aggression, irritability, numbness in hands, feet and brain, repeatedly washing hands, wearing clothes in
specific order, walking in a pattern and counting steps, and her conditioned has worsened in the past 2
months.
History of Presenting Illness:
My patient was in usual state of health when she first noticed the onset of her symptoms approximately 2
years ago. Initially, she began experiencing intrusive thoughts related to cleanliness and contamination.
These thoughts were followed by an overwhelming urge to engage in specific repetitive behaviors to
alleviate her anxiety. Patient found temporary relief by engaging in compulsive handwashing, counting, and
ensuring objects and tasks were completed in a specific manner.
Over time, her symptoms worsened, and the rituals became more time-consuming and compelling. Rukhsana
started counting water drops dripping from her hands and felt compelled to repeat actions until a certain
number was reached. She also developed a fixation on counting steps as she is walking, standing for minutes
and hours anywhere, washing hands repeatedly unless she is satisfied, going to washroom numerous of
times, putting glass first on the table, opening the bottle and then pouring water in it, turning the stove on
and off, following a specific pattern as she is wearing clothes and arranging money in a specific order.
Failure to follow these patterns would result in increased anxiety and distress. She spends 7-8 hours a day
performing these actions, The onset of her illness was sudden and has increased continuously. Due to this
condition, her performance is compromised, and she cannot carry out normal household chores. She doesn’t
socialize anymore, doesn’t like people. And she throws tantrums when someone withstands her from
executing these actions. She feels compelled to perform these rituals to prevent imagined harm or alleviate
distress. Her symptoms have significantly interfered with her daily life, causing disruptions in her household
responsibilities, relationships, and overall well-being.

Personal History:

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My patient is a married woman for 12 years. She is uneducated and a housewife. She has 2 daughters, and
she spends her day doing household chores. Her relationship with her husband is not good. She argues with
him a lot because he stops her from performing her acts. And she gets angry over it. Sometimes she doesn’t
even talk to him.
Family History:
Patient’s parents are deceased. She is the eldest of 5 siblings. And she meets them occasionally but doesn’t
have good relations with them. She doesn’t really like to meet the rest of her family. No one else in her
family has such an illness as her.
Past Medical History:
Patient has been to various doctors in the past 2 years, and she is on medications for her illness. Record is
unavailable. But no other significant medical history.
Past Surgical History:
She has had laparoscopy done a few years ago and it does not have any association to her mental illness.
Past Psychiatric History:
Unremarkable.
Past Forensic History:
Unremarkable.
Substance Use:
Unremarkable.
Pre-Morbid History:
Before the onset of illness, my patient used to be in a good mood. She liked to socialize with family and
other relatives. She had good relations with everyone and was an extrovert by nature. Her stress coping
mechanism was usually taking some time for herself and relaxing.

PSYCHOLOGICAL ASSESSMENT
1.Informal Assessment
2.Formal Assessment

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 Informal Assessment
Mental Status Examination:
Appearance: Patient’s grooming was mediocre. She looked slightly disheveled. Her hygiene was
compromised. Even after she washes herself multiple times and likes to be clean. Her clothing was okay, but
she had damaged skin on her feet.
Behavior:
My patient’s behavior was less cooperative at the beginning. She did not want to talk much. Her facial
expressions were blunt.
Speech:
Her speech was fine, and it was coherent as she explained her symptoms well.
Mood:
My patient was in a low and irritated mood.
Thought Process:
The content of my patient’s thoughts was her illness. As she kept mentioning things that she does and does
not like. She also portrayed guilt about her aggression.
Cognition:
My patient mentioned that she experienced slight difficulty in remembering things 2 years ago, but she
seemed fine at the time of consultation.
Perception:
My patient had an insight into her illness. She was aware of her symptoms, and she was disturbed due to her
repetitive thoughts and uncontrollable urge to perform certain tasks.

Formal Assessment
(___Test Applied_____)
(Result and scoring) Conclusion:
(___Test Applied_____)
(Result and scoring) Conclusion:

Diagnosed Disorder:

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 According to history and MSE, my most probable provisional diagnosis is OCD and co-morbid with
depressive illness.

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Case IV

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Information Identifying:
My patient, Muhammad Ismail, is 19 years old, resident of Multan. He studied till 3 rd Grade, and he is
unmarried.
Mode of Referral:
The patient came in general OPD.
Presenting Complaint:
My patient came in with a complaint of headache and high heartbeat. He shows symptoms of aggression and
reckless decisions. He fights with everyone and gets furious if he is not heard. He is over-religious and
mentioned that he hears voices. He is in an elated mood.
History of Presenting Illness:
My patient was in usual state of health when approximately 1-1.5 months ago, he began experiencing
persistent and intense headaches. Alongside this, he displayed aggressive behavior, frequently engaging in
arguments with his family members. The onset of these symptoms was sudden, and they have persisted since
then. He used to work at a juice shop but ceased going there due to the onset of his symptoms.
Unexpectedly, he developed an intense religious fervor, actively seeking out faith healers and participating
in religious gatherings. He claims to hear voices directly from Allah, believing that Allah communicates
with him. Moreover, he demonstrates a sense of superiority, emphasizing his religious practices such as
praying five times a day while criticizing his brother for not doing the same.
Despite these concerning behaviors, the patient has expressed a strong desire to get married next year.
Additionally, he pressures his family to purchase expensive items beyond their means. He insists on wearing
new clothes every day and reacts with anxiety and anger when denied. Remarkably, his sleep and appetite
remain unaffected.
Personal History:
My patient does not have any history of drug use.
Family History:
The parents of my patient are still alive. He has 2 siblings, and he is the youngest of the 3. One of his elder
brothers is married and does not live with them. The patient does not have good relations with his mother
and brothers as he keeps arguing with them although he has better relations with his father. The environment
of the house is okay.
Past Medical History:
My patient suffers with Asthma since his childhood, and it is genetically transferred to him from his mother
and grandmother. The patient uses inhalers for the treatment.

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Past Surgical History:
There is no significant Surgical History.
Past Psychiatric History:
The patient has been getting treatment from faith healers but that did not show any significant effects.
Past Forensic History:
No significant forensic history.
Pre-Morbid History:
My patient led a normal life before his illness started and he used to socialize with his friends and family
members. He did not use to go to Urs and Darbar before this illness.

PSYCHOLOGICAL ASSESSMENT
1.Informal Assessment
2.Formal Assessment

Informal Assessment
Mental Status Examination:
The patient was wearing many rings on his fingers that he bought from his faith healer. He was over
religious in nature and was wearing a necklace and carrying a counter too.
His speech was a bit distorted as he kept distracting and repeating the same thing again and again.
My patient was in an elated/happy mood.
The content of his thought processes was religion and marriage.
His cognition was okay.
Patient did not have the insight into his condition.

Formal Assessment
(___Test Applied_____)
(Result and scoring) Conclusion:
(___Test Applied_____)
(Result and scoring) Conclusion:

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Diagnosed Disorder:
My patient is diagnosed with Bipolar Disorder and he was experiencing a Manic Episode. And he has
Auditory Hallucinations as well as Sexual disinhibition.

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Case V

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Information Identifying:
Abdul Rasheed, 38 years old married man with 6 children lives with his wife. He is working in health
department as X-ray Technician and he is a resident of Taunsa Shareef.
Mode of Referral:
He was admitted through OPD 3 days ago.
Presenting Complaint:
My patient was concerned about his addiction of injection of King. Due to this injection his leg and foots has
swollen badly and the wound on his leg which was occurred due to the accident began to spoil and made an
infection on the wound and is gradually spreading to whole leg.
History of Presenting Complaints:
My patient was in his usual state of health when he was involved in a road accident almost 3 to 4 years ago.
As a result of the accident, he sustained an injury to his leg. Initially, he ignored it, but as the injury
worsened and severe pain developed in his leg, he finally sought medical attention. The doctor prescribed a
medication called King, which was administered to him via injections. Initially, he received one injection
per day, but as the pain intensified, he increased the dosage and started injecting it three times a day. He
developed and addiction of this painkiller almost 2 years ago and didn’t stop taking it. The injections were
administered directly into a vein. Unfortunately, he became addicted to these injections. As a result, his leg
wound deteriorated and eventually became infected, posing a risk of spreading throughout his entire leg.
The patient is now in severe pain and his wounds are not getting any better. There is another infection on his
arm where he used to inject the medicine. His hands and legs are swollen badly. It has impacted his physical
and mental health. He is not working anymore. And his daily life is compromised.
Past psychiatric History:
There is no past psychiatric history of patient.
Treatment History
He took the pain killers of Opioid for the pain in leg
Past Medical History:
No significant medical history.
Past Surgical History:
No significant Surgical History.
Family History:

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My patient have 6 children, 2 sons and 4 daughters. His elder daughter is 10 years old. His parents are alive.
He has a good relation with his family members. His environment is peaceful. None of his family members
have psychiatric, medical or surgical and substance use history.
Personal History:
My patient doesn’t have any birth complications. He is an educated person.
Drug History:
My patient take king injection from 2 years. He used to self inject. He takes 1 ml injection dose and takes 2
to 3 times in a day. When the pain in wound is severe, he increases the dose of injection according to it. He
also takes niswar. He inject injection in vein by himself. Due to this injection his physique is getting weaker
gradually.
Forensic History:
No significant forensic History.
Pre-Morbid Personality:
Before taking injection he was good and walk easily. Now he felt pain when he walks. On being asked about
his future plans,he wants to get better and want to left this injection and start his new life without this
injection.

PSYCHOLOGICAL ASSESSMENT
1.Informal Assessment
2.Formal Assessment

Informal Assessment
Mental Status Examination:
The patient is well-groomed and dressed appropriately. His psychomotor retardation appears to be normal,
and his physical appearance is good. However, he is uncooperative and not talkative. He refuses to discuss
his wound and his addiction to injections.
The patient’s speech is spontaneous, with a normal pitch. Although he is not talkative, his speech remains
coherent and relevant. His answers are appropriate and understandable.
The patient expresses guilt regarding his drug addiction. His mood is appropriate. His thoughts are normal,
well-structured, and there is no loosening of associations in his thinking.

xxi
The patient does not exhibit any delusions or hallucinations. His attention can be easily aroused, but he does
not fully concentrate. He avoids giving attention and providing information about himself and his addiction.
He attempts to ignore my questions.
However, the patient is able to accurately tell the time of day and the month of the year. He readily identifies
the place he came from and provides his name and details correctly. He demonstrates good orientation to
time and place.
The patient’s memory is intact, as he remembers what he ate and when he arrived at the hospital. His
intelligence is considered adequate, as he was employed in the health department as an X-Ray technician.
The patient displays good behavior overall, but he remains non-cooperative. He expresses a desire to
improve and lead a normal life, expressing his intention to quit using injections to facilitate his future
recovery.
The patient acknowledges his problems and recognizes the need for treatment.

Formal Assessment
(___Test Applied_____)
(Result and scoring) Conclusion:
(___Test Applied_____)
(Result and scoring) Conclusion

Diagnosed Disorder:

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 Appendix:
A. Permission Letter

Department of Applied Psychology

Bahauddin Zakariya University, Multan
No. PSY-101 /2023
Dated: 03 / July /2023
To,
Medical Superintendent
Allama Iqbal Teaching Hospital
Dera Ghazi Khan

Subject: Permission to facilitate in Internship Dear

Sir!

As an integral part of the BS Applied Psychology Program, our students are required to complete
internship for 6 weeks. The institute is doing its best to provide the students with quality education and
skills. We have to acknowledge that without the support of organizations, we can't deliver our students the
opportunities to learn practical skills in the field of Psychology. Your help in this regard will be a service to
uplift the quality of education in Pakistan. It is, therefore, requested that the students of this department may
kindly be facilitated in their Internship.

Thank you
Student's Name Roll. No

__NAME___ BSAPM-20-

Dr. Humaira Latif

Coordinator Internship
Assistant Professor
Department of Applied Psychology
B.Z.U, Multan

B. Internship Certificate

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(Picture-Received by Hospital)

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 C. Scales Applied on Patients

(Filled-Scales Applied on and filled by patients)

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