CASE REPORT
Patient details:
Name: Akash Singh DOB: 09/05/1999 Date: 07/06/25
Sex: Male Age: 26
Marital status: Single
Father’s/ husband’s name: Ajay Vir Singh
Address: C-217, Delta Greater Noida
Current living status: With Family
Type of family: nuclear
Referral: Self
INFORMANT’S DATA
Name:
Relationship to the patient
Chief Complaints:
From patient From relatives
• Stress N.A.
• Anxiety
• Day dreaming
History of present illness
Duration of illness: 10 YRS
Sleep: normal
Diet: Decreased
Description of problem:
The client is unable to talk with boys, specially girls. feeling of
loneliness, no personal room , Since school and college, client found it
hard to make close friendships or approach someone they're interested
in. client would notice girls but never approached, they have 2.5 years
of work experience, earn well, and manage savings , this shows they are
responsible, stable, and disciplined. client also planning a trip, which
shows they're trying to break out of routine and explore new
experiences. They often daydream about having a girlfriend, going on
trips together, or getting married. He is a very shy person and has a
lot of issues talking to girls. He loves video games. He has two
sisters, neither of whom are married yet. The younger one is
ready for marriage, but it hasn’t happened because of the older
one. Akash has negative thoughts about himself, which causes
him stress. In his first job, he didn’t earn enough money, but
he’s satisfied with his current job. Akash wants to get married,
but he’s afraid if he’ll find a good partner or not.
Past history:
Psychiatric : medication, anxiety attack.
Drugs/ alcohol/ smoking (what/ how much/ since when): alcohol-
occasionally
Any suicidal attempt: In Covid,he was in depression at that time, ‘He
felt he will die’
Mental retardation: Start walk, and panic attack
Personal history:
Perinatal history: C-Section
Early development history: Normal
Educational history: B-Tech in mechanical, In class 5th he was good
Social anxiety starts from class 6th academically weak.
Sexual history: Masturbation ,watching porn-content foreign
Weakly -7 days 1 time with watching porn.
Occupational history: satisfied.
Family history:
Akash belongs to a nuclear family. He has two sisters, and no one listens
to him at home. His sisters aren’t married yet because the older one
isn’t married, which is holding back the younger one’s marriage, even
though she’s willing. Akash has recently planned a trip with his sister for
August.
Pedigree Drawing :
Marital status: Plan to marry at 30 age
Premorbid personality: Social phobia, hobbies painting
guitar,cartoon,unable to speak .
MENTAL STATUS EXAMINATION
General appearance and behavior : regression, childlike behavior.
Facial expressions: over smiling
Eye to Eye contact : maintain gazes
Posture: slow, relaxed
Psychomotor activity: over smiling on response, excitement
Rapport: Maintain
Mood and affect
Objective affect : Personality issues over happiness
Subjective affect : Personality social phobia
Speech: soft intensity, abnormal changes in pitch, slow tone and
appropriate reaction time
Deviation : loosing of association
Content: worthlessness
Perception : day dreaming
Hallucinations: not present
Illusions: not present
Cognition:
Conscientiousness: conscious of time, place and person
Attention: normal
Concentration : normal
Memory: normal immediate and recent memory
Abstract thinking: Proven testing ,similarities and difference.
Judgement: test judgement , social judgement
Insight: emotional insight, aware about illness need treatment
Plan and management:
Diagnosis: Recognizing both psychological and physical symptoms,
and assessing their duration and impact on daily life.
Plan :To manage stress and anxiety, we can use simple and healthy
habits in daily life. Deep breathing, regular exercise, and getting
enough sleep help calm the mind and body. Talking to someone we
trust, like a friend or counselor, can also make us feel better. Staying
organized and taking breaks during work or study can reduce
pressure. Positive thinking and relaxing activities like listening to
music or going for a walk also support mental health.
Treatment : using therapy like CBT to help individuals identify and
change negative or unhelpful thought patterns and behaviors to
improve their overall mental well-being
Stress management, in simple terms, is about learning to handle
stress effectively. It involves using techniques to reduce or manage
the negative effects of stress on your mind and body.
