CASE HISTORY - 1
IDENTIFICATION DATA
NAME : XXX
AGE : 22
SEX : Female
MARITAL STATUS : Unmarried
EDUCATION : 10th
OCCUPATION : Cashier
INFORMANT - Father,Mother ,Sis Sister
PRESENTING CHEIF COMPLAINT
ONSET - Insidious
DURATION- 6months
COURSE- Continuous to write about chief complaints also.
HISTORY OF PRESENT ILLNESS
Vomitting - 10 days in this history of present illness write about detailed explanation.
Self Talk - 3 months
Self laugh
Poor self care
Poor eye contact
Hearing voices
Pro occupation
Isolation
Lack of attention
Lack of concentration
PAST PSYCHIATRY AND MEDICAL HISTORY
First she was admitted at sunitha hospital in 1 week and followed medicines 6months. Then,
she admitted had been admitt kumaran medical on 3 days .
FAMILY HISTORY
PERSONAL HISTORY
PERINATAL HISTORY - Cesarean delivery
CHILDHOOD HISTORY- Normal Milestone
EDUCATIONAL HISTORY- 10th pass , Sports player
PUBERTY- Secondary sex characteristics developed, 15th age attended
MENSURAL & OBESTIC - Regular
OCCUPATIONAL HISTORY- Cashier
SEXUAL AND MARITAL HISTORY- Nil
PREMORBID PERSONALITY (PMP )- Introvert
MSE
GENERAL APPEARANCE
ATTITUDE - Calm
COMPREHENSION - Impaired
GAIT / POSTURE - Abnormal
MOTOR ACTIVITIES- Abnormal involuntary movements
SOCIAL MANNER - Decrease
RAPPORT - Difficult
HALLUCINATORY BEHAVIOR - Auditory Hallucination
SPEECH
RATE AND QUANTITY OF SPEECH - Absent
VALUE AND TONE OF SPEECH - Decrease
FLOW AND RHYTHM OF SPEECH - Non verbal
3) MOOD AND AFFECT
Normal
Anxious
4) THOUGHT
STREAM OF THOUGHTS - Nil
CONTENT OF THOUGHTS - Nil
ABSTRACT THINKING - Nil
PERCEPTION - Hallucination
COGNITION
CONSCIOUSNESS - Unconscious
ORIENTATION - Abnormal
ATTENTION - Poor
CONCENTRATION - Poor
MEMORY - Abnormal
INSIGHT - No
DIAGNOSIS - Undifferentiated Schizophrenia
CASE HISTORY 2
IDENTIFICATION DATA
NAME : YYY
AGE : 53
SEX : Male
MARITAL STATUS : Married
EDUCATION : 6tg
OCCUPATION : Business
INFORMANT - Son
PRESENTING CHEIF COMPLAINT
ONSET - Insidious
DURATION- 3year
COURSE- Continuous
HISTORY OF PRESENT ILLNESS
Fever
Heart Attack
Somatic Complaints
Sleep disturbances
Sucidal idealation
Isolation
Tiredness
Feeling of worthlessness and Hopelessness
Reduced activities
Easily fatigued
Appetite changes
Forgetfulness
PAST PSYCHIATRY AND MEDICAL HISTORY
First he went Seetha Lakshmi hospital and admitted 1week . Then he came agal
hospital he had been take treatment for 3months. He went home but he doesn't take
medicine regularly so return he come to the agal hospital.
FAMILY HISTORY
PERSONAL HISTORY
PERINATAL HISTORY - Normal Delivery
CHILDHOOD HISTORY- Normal Milestone
EDUCATIONAL HISTORY- 6th
PREMORBID PERSONALITY (PMP )- Introvert
INTERPERSONAL RELATIONSHIPS WITH FAMILY - Normal
USE LEISURE TIME - Poor
PRODOMINANT MODE - Stable
ATTITUDE TO WORK AND RESPOSIBILITY - Flexibility
ATTITUDE TO SELF - Low self esteem
RELIGIOUS BELIEFS AND MORAL ATTITUDE - Follow
MSE
GENERAL APPEARANCE
ATTITUDE - Calm
COMPREHENSION - Fully functioning
GAIT / POSTURE - Normal
MOTOR ACTIVITIES- Trimors
SOCIAL MANNER - Normal
RAPPORT - Easy to establish
HALLUCINATORY BEHAVIOR - Nil
SPEECH
RATE AND QUANTITY OF SPEECH - Present, Poor speech
VALUE AND TONE OF SPEECH - Value and tone decrease
FLOW AND RHYTHM OF SPEECH - Smooth
3) MOOD AND AFFECT
Normal
Depression
4) THOUGHT
STREAM OF THOUGHTS - Normal
CONTENT OF THOUGHTS - Hopelessness, Worthlessness
ABSTRACT THINKING - Normal
PERCEPTION - Hallucination
COGNITION
CONSCIOUSNESS - Conscious
ORIENTATION - Oriented
ATTENTION - Attentive
CONCENTRATION - Concentrating
MEMORY
IMIATE RETENTION AND RECALL - Intact
RESEND MEMORY - Intact
INTELLIGENCE - Normal
INSIGHT - Present
DIAGNOSIS - Bipolar
CASE HISTORY 3
IDENTIFICATION DATA
NAME - YYY
AGE - 15
SEX - Male
MARITAL STATUS - Unmarried
EDUCATION - 10th
OCCUPATION - Nil
INFORMANT - Father,Mother
PRESENTING CHIEF COMPLAINTS
ONSET - Insidious
DURATION - 1year
COURSE - Continuous
HISTORY OF PRESENT ILLNESS
Sleep disturbances
Forgetfulness
Angry
Suspicious about family members
Auditory hallucinations
Somebody stealing his brain
Somebody watching him
Self worth, Hopeless
Sucidal thoughts due to memory loss
Isolation
Worried about future life
Tiredness
PAST PSYCHIATRIC AND MEDICAL HISTORY
Initially consolted with Dr Ramakrishnan and was diagnosed with schizophrenia with
hallucination as a positive symptom. Then tried homeopathy as an alternative treatment and
was taking flower medicine. Currently is taking therapy and medication appreciate to
schizophrenia .
FAMILY HISTORY
PERSONAL HISTORY
PERINATAL HISTORY - Normal Delivery
CHILDHOOD HISTORY - Normal Milestone
EDUCATION HISTORY - 10th
PREMORBID PERSONALITY - Introvert
INTERPERSONAL RELATIONSHIPS WITH FAMILY MEMBERS - Normal
USE LEISURE TIME -
PRE DOMINANT MODE - Stressful life event
ATTITUDE TO SELF - Failure
ATTITUDE TO WORK AND RESPOSIBILITY - Flexibility
RELIGIOUS BELIEF AND MORAL ATTITUDE - Follow
MSE
GENERAL APPEARANCE
ATTITUDE - Calm
COMPREHENSION - Fully functioning
GAIT/POSTURE - Normal
MOTOR ACTIVITIES - Restlessness
SOCIAL MANNER - Normal
RAPPORT - Normal
HALLUCINATORY BEHAVIOR - Auditory hallucination
SPEECH
RATE AND QUANTITY OF SPEECH - Present
VALUE AND TONE OF SPEECH - Normal
FLOW AND RHYTHM OF SPEECH - Normal
MOOD AND AFFECT
Normal
Anxious
THOUGHT
STREAM OF THOUGHTS - Normal
CONTENT OF THOUGHTS - Normal
ABSTRACT THINKING - Normal
PERCEPTION - Hallucination, Delusion
COGNITION
CONSCIOUSNESS - Conscious
ORIENTATION - Oriented
ATTENTION - Attentive
CONCENTRATION - Concentration
MEMORY
IMIATE AND RETENTION RECALL - Intact
RESEND MEMORY - Intact
INSIGHT - Present
DIAGNOSIS - Paranaid schizophrenia
CASE HISTORY 4
IDENTIFICATION DATA
NAME :YYY
AGE : 34
SEX : male
MARITAL STATUS : married
EDUCATION : Nil
OCCUPATION : Nil
INFORMANT - Wife
PRESENTING CHEIF COMPLAINT
ONSET - Insidious
DURATION- 1months
COURSE- Continuous
HISTORY OF PRESENT ILLNESS
Suspicious about Wife and her family
Somebody set a zip in our head
Poor self care
Poor eye contact
Isolation
Lack of attention
Lack of concentration
PAST PSYCHIATRY AND MEDICAL HISTORY - Nil
FAMILY HISTORY
PERSONAL HISTORY
PERINATAL HISTORY - Normal delivery
CHILDHOOD HISTORY- Normal Milestone
EDUCATIONAL HISTORY- Nil
SEXUAL AND MARITAL HISTORY- Abnormal, Love Marriage
PREMORBID PERSONALITY (PMP )- Introvert
MSE
GENERAL APPEARANCE
ATTITUDE - Calm
COMPREHENSION - Impaired
GAIT / POSTURE - Normal
MOTOR ACTIVITIES- Nil
SOCIAL MANNER - Normal
RAPPORT - Normal
HALLUCINATORY BEHAVIOR - Auditory Hallucination
SPEECH
RATE AND QUANTITY OF SPEECH - Present
VALUE AND TONE OF SPEECH - Normal
FLOW AND RHYTHM OF SPEECH - Normal
3) MOOD AND AFFECT
Normal
Anxious
4) THOUGHT
STREAM OF THOUGHTS - Suspicious
CONTENT OF THOUGHTS - Suspicious
ABSTRACT THINKING - Abnormal
PERCEPTION - Delusion
COGNITION
CONSCIOUSNESS - Conscious
ORIENTATION - Orientation
ATTENTION - Attentive
CONCENTRATION - Normal
MEMORY
IMIATE RETENTION AND RECALL - Normal
RESEND MEMORY - Normal
INSIGHT - Absent
DIAGNOSIS - Schizophrenia
CASE HISTORY 5
NAME - YYY
AGE - 33
EDUCATION - 10th
OCCUPATION - Pumb operator
MARITAL STATUS - Married
CHIEF COMPLAINTS
Appetite
Tiredness
Body pain
Angry
ALCOHOL USE DETAILS
CURRENT PATTERN
AMOUNT - 140ml×2
PROBLEM & ISSUE - Friends Compelsion , Enjoyment
LAST DRINK - 1.10.2022 Saturday (180ml)
LONGITUDINAL PATTERNS
The patient was started drinks his 15th age due to his friends focusing.
COMPLICATION DUE TO ALCOHOL USE
PERSONAL - Increase workload
FAMILY - Family fights
SOCIAL - Self Criticism
OCCUPATION - Not working perfect
FINANCIAL - Nil
HEALTH - No health problem
A) PHYSICAL - Trimors
B) PSYCHOLOGICAL - Mind upset
SEXUAL - Nil
LEGAL - Nil
ABSTINENCE PERIOD IF ANY: (WITH OR WITHOUT Rr) - Smoking
DUE TO MEDICINE - Nil
REASON OF RESTARTING - Friends focusing and his own enjoyment
COMORBIDITY
1) OTHER SUBSTANCES - Smoking
2) OTHER PSYCHIATRIC ILLNESS - No psychiatric illness here
PAST HISTORY - Nil
FAMILY HISTORY
PERSONAL HISTORY
CHILDHOOD HISTORY - Normal
EDUCATIONAL HISTORY - 10th
OCCUPATIONAL HISTORY - Pumb operator
MARITAL HISTORY - Love Marriage on 21th age
PREMORBID PERSONALITY - Calm, Extrovert
PERSONALITY DISORDERS IF ANY - No personality disorders
PHYSICAL EXAM - Nil
MSE
GENERAL APPEARANCE
ATTITUDE - Calm
BEHAVIOR - Fully functioning
SPEECH - Normal
CONSCIOUSNESS - Conscious
ATTENTION - Intact
CONCENTRATION - Intact
ORIENTATION - Oriented
PERCEPTION - No perception and thought disturbances
INTELLIGENCE - Normal
MEMORY - Normal
MOOD AND EFFECT - Calm
INSIGHT - Present
