CASE HISTORY

SOCIODEMOGRAPHIC DATA

Name : YR

Age : 35 years

Gender : Female

Education : Degree

Marital status : Married

Religion : Hindu

Occupation : Nil

Residential area : Rural

Family type : Nuclear

Socioeconomic status : Middle

PRESENTING COMPLAINTS

According to the patient, she has a problem with encountering crowds which would result in
difficulties of increased heart, breathing difficulties, dizziness, and faintness for sometimes.
Because of these problems, she was unable to go out of the house, shop, public place, etc. and
unable to travel in public transport. She also experienced the same in the darkness.

INFORMANTION

Informant : Father and Sister.

The information provided is reliable and adequate.

CHIEF COMPLAINTS

 Fear of going to public places

 Tension, sweating
  Breathing difficulties
 Increased heart rate
 Choking sensation
 Dizziness
 Fear of dying and losing control
 Fare of darkness, crowd and enclosed place, etc.

Mode of onset : Abrupt

The course of illness : Continuous
Duration of illness : 4 month
Precipitating factor : None
Perpetuating factor : None

HISTORY OF PRESENT ILLNESS

NEGATIVE HISTORY

There is no history of significant head injury, epilepsy, neurological disorders and no history of
substance abuse.

TREATMENT HISTORY

She has a history of treatment in WIMS hospital, Meppadi. She took medication for
around 4 days.

PERSONAL HISTORY

Birth history:
She was a wanted child. The immediate birth cry was present. She has been delivered as a full
term baby. The patient’s mother has no significant history of drug usage or medication.

Mile stone development:

Speech, motor, cognitive and social development was normal.

Childhood history:
No history of childhood disorders like ADHD, conduct disorders, etc.

Educational history
She had a history of good interpersonal relationships with teachers and peer groups.

Marital history
She is married and has a baby. She maintains a good relationship with his husband. Her husband
has to stay away from the house due to his work.

Sexual history
Unknown

Pre-morbid personality:
She was an active person and interacted with others without any problem.

FAMILY HISTORY

Family structure:

35 years

The patient is from a middle economic status family. The patient has her father, mother
and her child in her house. His father is very supportive. Her husband has to stay far away from
the house due to his work. He only comes to the house during holydays. There was no history of
mental disorder in her family.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE

Dressing pattern:
She has maintained personal cleanliness and hygiene
Cooperativeness:
She was corporative

Eye to eye contact:

Eye contact was established and maintained

Rapport:
Rapport was established and maintained.

Psycho-motor activity:
The patient has normal psychomotor activity.

ATTENTION AND CONCENTRATION

Digit forward : 6
Digit backward : 5

Attention and concentration are aroused and sustained.

MEMORY

Immediate memory:

The patient was asked to recollect the five words given;

Paper Char Pipe Box Cap
He answered the same.
The immediate memory of the patient was intact.

Recent memory:

Question : What you had for breakfast?

Answer : Dosa
The answer was right. Therefore his recent memory is intact.

Remote memory

Question : What is your date of birth?

Answer : 19/2/1984
Remote memory was intact.

INTELLIGENCE

General knowledge:

Question : Which is the Capital of India and America?

Answer : New Delhi and Washington DC

General knowledge is average.

Arithmetic area:
Question : 101 + 61
Answer : 162
Question : 107 - 7
Answer : 100
Question : 500×2
Answer : 1000
Her arithmetic intelligence was average

Comprehension:

She was asked what is the purpose of the license. Her answer was it is the eligibility for driving
vehicles.
She has average comprehension.

ABSTRACT THINKING

He was asked to explain the proverb “A friend indeed a friend in need”. Her explanation was a
friend must be there for support when the need comes.
She has a conceptual level of abstract thinking

ORIENTATION

The patient was asked what the time, day, date, month, and year? Can you introduce yourself? At
which place you are standing now? Do you know who we are? The patient's answer to each
question was appropriate.

The patient was oriented to time, place, and person.

VOICE AND SPEECH

The voice was audible. The speech was coherent, fast, goal-directed and the reaction time was
quick.

PERCEPTUAL DISTURBANCE

Perceptual distortions : No illusion

Perceptual deception : No hallucination

THOUGHT DISTURBANCES

Stream of thought:
Normal

Content of thought:
Her content of thought include Fear of closed and dark places, Increased Heartbeat, Increased
Palpitation, and Fear of dying

Possession of thought:
Normal

Form of thought:

Normal

Judgment

Test judgment:

She was asked what will you do when you got a stamped letter with an address written on it. She
said she will put it in a nearby post box.

The test judgment was good.

Personal judgment:

She was asked what she wants to do after leaving the hospital.
Personal judgment was good.

Social judgment:
She was asked what he will do when we come to your home as guests. Her answer was she will
welcome us and give food.

Social judgment is good.

MOOD AND AFFECT

Mood : Feeling Tensed

Affect : Anxious

INSIGHT

Present

DIAGNOSTIC FORMULATION

PROVISIONAL DIAGNOSIS

TREATMENT PLAN