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