CASE HISTORY TAKING OF AN ADULT

A) Background Information of Client/Patient*:

Date of assessment: 11-11-2024
Name : Ms.MG
Age of patient/respondent: 28Yrs
Date of Birth: 19-06-1996
Sex: Female
Education: BSc. Graphic design &Animation
Occupation: Graphic designer
Residence: Trivandrum
Family Structure: Nuclear/Joint/Other : Extent
Background Information of Informant:
Name of the informant: Mr.MK
Relationship with the patient: Brother
Length of acquaintance: 28Yrs
Adequacy of information: Adequate
Reliability of information: Reliable
B) Specific Information
1. PRESENTING COMPLAINTS (chief complaints that prompted the
individual/family to come to the hospital/centre/or seek intervention/help)
According to patient: She reports, experiencing cycles of intense closeness
followed by sudden withdrawal. Furthermore, for the past three years, she
has reported a persistent sense of aloofness, feeling detached and
disconnected from others, which exacerbates her difficulties in forming
meaningful relationships.
 According to informant: The index patient and her brother report a range of
troubling behaviours and emotional challenges. She exhibits aggressive
behaviour, characterized by intense anger that often results in verbal
outbursts directed at family, friends and colleagues. Additionally, she has
engaged in self-harming behaviours, including cutting and burning during
periods of emotional distress. She also has made attempts to take her own
life. Her emotional instability is marked by rapid mood changes, frequently
triggered by interpersonal conflicts or feelings of rejection. This instability
has contributed to poor interpersonal relationships, as she struggles to
maintain stable connections

2. DURATION OF ILLNESS
How long the patient has been ill?
1095days / 36months / 3years

3. PRECIPITATING FACTORS
Onset (acute or gradual): Gradual
Course of illness: Her father’s death during high school period had a profound
impact on her emotional wellbeing. She felt a deep sense of loss and began to
withdraw from her family. Her brothers, while supportive, were often busy with
their own lives, which left her feeling isolated.

4. FAMILY HISTORY
Family type: Nuclear/ Extended/ Joint: Extent Family
Socio-economic status: Upper/ Middle/ Lower: Middle
Family tree:

Family tree:
Sl.no Relation with patient Age Education Occupation Health& Personality

Family interaction and communication: Supportive and caring each other’s

Family history of psychiatric illness: No psychiatric illness in family
5. PERSONAL HISTORY
Date of birth: 19-06-1996
Place of birth: SUT HOSPITAL TVM.
Mother’s condition during pregnancy: Healthy
Full term birth/ normal delivery/others: Normal
Any delay in early developmental milestones (for example: neck holding,
sitting, walking, talking etc.): Yes/ No : No
If yes, please mention details: Nil
Neurotic symptoms in childhood (like temper tantrums): Yes/ No: No
If yes, please mention: Nil
Night terrors: Yes/ No : No
Behaviour problems like thumb sucking or nail biting etc.: Yes/No: Yes
If yes, please mention: Used to bite nails at early childhood & sometimes at
present adulthood

Health during childhood

If patient suffered from any childhood infections or illness? Yes/ No: No
If yes, please mention if there was any effect of illness on development? : Nil
If patient suffered from any infantile convulsions? Yes/No: No
School: Normal at school
Special abilities/disabilities: Nil
Performance in academics: Good performance
Number of friends: 4 (Few friends)
Relationship with peers : Alienated
Participation in co-curricular activities like drama/sports etc.: Nil
Hobbies and interests: Hobbies include drawing and colouring, Interested in Art

Occupation
Age of starting work: 25Yrs old
Ambition in life: To be a great artist
Present jobs held:
- Designation: Graphic designer (Freelancer)
- Wages: 40,000 (approximately)
Satisfaction in work: Feels frequently fluctuated in her work
Present economic conditions: Average
Menstrual history (for female patients)
Age of 1st period: During her 12th age
Regularity/duration: Regularly in each month
Amount of pain: Sustainable Pain
Sexual inclinations and practice
Sexual information/how acquired: Acquired through studies & from family
members and peer group
Masturbation/sexual fantasies: Masturbation
Homosexuality/heterosexuality: Heterosexuality
Marital history
Spouse’s age: Nil
Occupation: Nil
Personality: Nil
Compatibility: Nil
Mode and frequency of sexual intercourse: Nil
Sexual satisfaction: Nil
Contraceptive measures: Nil

Children
Chronological list of children and miscarriages: Nil
Sl.No. Years of birth Name Sex Personality

Medical history
Did the patient undergo any: Nil
 major illness
 operation
 accidents
 surgical problem
If yes, Please mention details:
Past psychiatric history
Information of patient’s past psychiatry record: Nil
 Dates:
 Duration:
 Symptoms:
 Diagnosis:
 Treatment:
Pre-morbid Personality
Ask the patient and informant to describe her or his personality before the
illness started. For instance:
i) Social relations with
 Family: Normal relation with family & was highly affectionate towards late
father
 Friends: Normal relation with friends
 Relatives: Normal Personality
 Society: Normal Personality
 Workmates: Normal Personality
ii) Intellectual activities like:
Hobbies: Drawing
Interests: Art
 Memory: Intact
 Observation: Normal observation
 Judgement: Intact
iii) Mood of patient:
Bright/cheerful: Bright
 Despondent:
 Optimistic: Yes
 Pessimistic:
 Self depreciative:
Satisfied: Yes
 Stable: Yes
 Unstable:

iv) Character
 Attitude to work or responsibility: Well-maintained attitude
 Interpersonal relationships: Normal
 Standards in religious/social/health matters: normal standards
v) Fantasy life
 Frequency and content of day dreaming: Nil
vi) Habits
 Eating/alcohol consumption: Nil
 Self-medication: Nil
 Tobacco consumption: Nil

MENTAL STATUS EXAMINATION

INVENTORY
1) GENERALAPPEARANCE & BEHAVIOUR
i) General appearance
 Physique and body build:
Approximate height: 160cm
Weight: 50kgs
Appearance: Appears good
 Looks: Comfortable/Uncomfortable: Comfortable
 Physical health: Normal
Grooming: Well groomed
Hygiene: Adequate
Self-care: Good
 Dressing: appropriate/adequate/any peculiarities: Adequate
 Non-verbal expression :Normal
 Mood: Elevated mood
 Effeminate/masculine: Effeminate
ii) Attitude towards the Examiner
Is the patient : Cooperative
 Cooperative
 Guarded
 Evasive
 Hostile
 Attentive
 Interested/disinterested/apathetic
 Any odd behaviour
iii) Comprehension
Can patient understand the questions? : Intact, fully
 Intact/impaired (Partially/fully)

iv) Gait and posture

Posture Normal Abnormal
Way of sitting Normal

Standing Normal

Normal
Walking

v) Motor Activity
This is observed while interacting with the patient.
: Increased, Social withdrawal,
 Increased/Decreased
 Excitement/Stupor
 Abnormal involuntary movements: Tics, Tremors
 Restlessness
 Catatonic signs:
 Mannerisms (habitual involuntary movement)
 Stereotypes ( repetitions of physical activities)
 Posturing (strange, fixed and bizarre bodily positions)
 Waxy flexibility (condition in which person maintains the body position in
which he or she is placed)
 Negativism ( verbal or non-verbal opposition to suggestion)
 Ambitendency (making series of movements that don’t reach the goal)
 Stupor ( state of decreased activity and less awareness of surroundings)
 Echolalia (repetitions of words or phrases)
 Social withdrawal/autism
 Compulsive Acts: Normal
Rituals: Normal
Habits: Normal
vi) Social manner with non verbal behaviour : Decreased
 Increased
 Decreased
 Inappropriate
Eye contact: Hesitant eye contact
 Gaze aversion
 Staring vacantly
 Hesitant eye contact
 Normal eye contact
vii) Rapport
Whether a working empathetic relationship can be established with the patient?
Yes/ No: Yes
viii) Hallucinatory behaviour
Ask the patient if she or he hears some voices in absence of any external stimuli
or whether the family members notice the following kinds of behaviours in the
patient: Nil
 Smiling or crying without any reason
 Muttering/ talking to self (non social speech)
 Odd gesturing in response to auditory/visual/olfactory
 Tactile hallucinations

II) SPEECH
i) Rate with quantity of speech
Observe the patient during the interview for the following:
 Speech: Present / Absent: Present
 Spontaneous speech: Yes/ No: No
 Productivity: Increased / Decreased: Decreased
 Rate: Increased / Decreased / Appropriate: Appropriate
 Pressure or poverty of speech: Normal pressure
ii) Volume with tone of speech
On the basis of your interaction with the patient notice whether the speech is:
 Increased/decreased (its appropriateness): Decreased
 Low/high/normal pitch: Normal pitch
iii) Flow with rhythm of speech
Observe the patient’s speech; whether it is:
 Smooth/hesitant: Hesitant
 Sudden blocking (disruption of thought or break in flow): Yes
 Derailment (breakdown in logical connections between ideas): No
 Stuttering/stammering: No
 Circumstantiality (including irrelevant details and returning to the point) :No
 Tangentially (responding to the topic being discussed but not answering the
question posed): No
 Word salad (incoherent mixture of words): No
 Verbal stereotypy (repeating similar words again and again): No
 Flight of ideas (shifting from one idea to the next): No
 Clang association (thoughts associated with sounds rather than words; eg.,
band,,lang, tang): No

III) MOOD WITH AFFECT

Mood
i) Quality of mood
Subjectively: How do you feel?
Objectively: By examination
 Stability of mood: Over a period of time: Unstable
 Reactivity of mood: Variation in mood with stimuli: Yes
 Persistence of mood: Length of time the mood lasts:

ii) Affect
Observe what the patient’s demeanor reflects about the following:
 Quality of affect
 Range of affect (of emotional changes displayed over time): Present
 Depth or intensity of affect: Normal/increased/blunte: Increased
 Appropriateness of affect: In relation to thought and surrounding
Environment : Intact
 Mania: Euphoria, elation, exaltation, ecstasy: No
 Anxiety: Anxious, restless: No
 Depression: anxious, restless, sad, irritable, angry, auhedonia : Sad
 Schizophrenia: Shallow, blunted, indifferent, restricted,
inappropriate, labile, auhedonia : No

IV) Thought
i) Stream and form of thought
 Spontaneity: Present/ Absent: Present
 Productivity: Present/ Absent: Present
 Flight of ideas (shifting from one idea to the next) : Present/ Absent : Absent
 Prolixity/ordered flight of ideas: Present/Absent: Absent
 Poverty of content of speech: Present/Absent: Absent
 Thought blocking (sudden disruption in flow of thoughts): Present/ Absent)
: Present
 Continuity of thought: Present/ Absent): Present
 Relevant to questions asked: Yes/ No : Yes
Observe the following behaviour in the patient:
 Any loosening of associations: Present/ Absent: Present
 Tangential circumstantialities: Present/Absent: Absent
 Illogical thinking: Present/Absent: Absent
 Preservation: Present/Absent: Present
 Variegation: Present/Absent: Absent
ii) Content of thought
 Obsessions: Present/Absent: Present
 Contents of phobia: Present/Absent: Absent
 Delusion: Present/Absent: Absent
 Over valued ideas: Present/ Absent: Present

Observe the following contents in thoughts of the patient:

 Ideas of persecution : Present
 Reference: Nil
 Grandeur: Nil
 Love : Present for family
 Jealously : Nil
 Guilt : Present
 Nihilism : Nil
 Poverty : Nil
 Somatic symptoms :
 Hopelessness : Present
 Haplessness : Present
 Worthlessness : Present
 Suicidal ideation : Present

V) Perception
i) Hallucinations
 Auditory/visual/olfactory/gustatory/tactile (whether the patient hears voices
discussing something about him/her, smells any unusual odours, feels certain
sensations in the absence of any external stimuli): Yes/ No : No
If ‘yes’ : No
Elementary (sounds) or complex (voices) (hears certain sounds like the dripping
of a tap or a sound which is repetitious in nature): Yes/ No: No
What is heard/how many voices, when, male or female, 2nd or 3rd person?
Nil
During wakefulness/hypnagogic (while going to sleep) or hypnopompic (while
getting upfrom sleep); for example, sees a human figure while falling asleep or
waking up?
Nil
ii) Ask the patient regarding whether she or he reports to have experienced
any of the following:
 Illusions/misinterpretations (misperception of certain stimuli like mistaking a
rope for a snake): Yes/ No: No
 Depersonalization/de-realization (feelings of unreality regarding self or the
environment):Yes/ No: No
 Somatic passivity phenomenon (feeling that any external agency is
controlling one’s actions like making one do certain acts): Yes/ No: No

VI. Cognitive Assessment

i) Consciousness
Check for whether person is in a wakeful state by observing her or him as well
as through the way she or he responds verbally and non-verbally towards the
examiner.
 Conscious: Yes
 Confusion
 Somnolence
 Clouding
 Delirium
 Stupor
 Coma
ii) Orientation
 Time : Ask Time: 11:10am (Accurate)
Date: Oriented
Day: Oriented
Month: Oriented
Year: Oriented
Reason: Oriented
Time spent in centre/hospital: Oriented
 Place: Ask present location: Kazhakootam (Oriented)
Building: MIND FREE (Oriented)
City: TVM (Oriented)
 Person: Ask name: Ms.MG
Her or his role in the setting: Oriented
People around him/her: Oriented
iii) Attention
- Easily aroused/sustained: Sustained
- Can repeat digit : Yes
iv) Concentration
 100 – 7 test = 93 (Accurate)
 40 – 3 test (keep on subtracting 3 from 40 until he/she reaches 0 like 40,37,
34) : (Accurate)
 Count backward from 20 : (Accurate)
 Names of months /days of week in reverse order:(Accurate)
v) Memory
 Immediate memory
Digit span test (ask the patient to repeat the digits spoken by the examiner
forwards or backwards): Intact
 Recent memory
Ask how did the patient come to the room/hospital? : By car (Intact)
What foods did he have for breakfast? : Dosha and chammanthi (Intact)
What foods did he have the previous night? : Chapathi and dal curry (Intact)
 Remote memory
Birth date: 19-06-1996
Date/place of marriage: Nil
Any relevant questions from past: Intact
vi) Intelligence
 General information
Current Prime Minister, capital of India : - (Intact)
 Simple tests of calculations
( 4 + 5) = 9 (Intact)
vii) Abstract thinking
 Proverb testing: (‘every cloud has a silver lining’; ‘people who live in
glass houses should not throw stones’; ‘Sour grapes’.) : Intact
 Similarities with analogies: ‘‘what is similar between banana and orange, dog
and cat, table and chair?’’ : Intact

VII. INSIGHT
Insight is rated on 6 points scale given below:
1. Complete denial of illness. Yes/ No : No
2. Slight awareness of being sick and needing help, but denying it at the same
time. Yes/No : No
3. Awareness of being sick, but it is attributed to external or physical factors.
Yes/ No : No
4. Awareness of being sick, due to something unknown in self. Yes/ No :Yes
5. Intellectual insight : Awareness of being ill, and that the symptoms/failures in
social adjustment are due to over particular irrational feelings/thought ; yet does
not apply this knowledge to the current/future experiences. Yes/ No : Yes
6. True emotional insight: Awareness of being ill leads to significant basic
changes in the future behaviours and personality. Yes/ No :Yes

VIII) JUDGEMENT
i) Observed during interview, the ability to assess a situation correctly and act
appropriately in that situation like social judgement
ii) Test judgement by asking what patient would do in particular situations, by
asking questions such as

1. If you are walking on the road, and find a sealed envelope with address and
stamp lying on the street, what will you do?
Ans:- Will take it to the nearest post office for posting or will hand over to them.
2. If you have gone to watch a movie in a theatre, and suddenly the theatre
catches fire, what will you do?
Ans:- First I will make others aware of it.
3. If you find an injured child on the road, what would you do?
Ans:- I will call an ambulance and will take him to hospital. After that I will
inform his parents
4. If it is raining outside, what should you do?
Ans:- I will not go outside unnecessarily. If I need to go I will take an umbrella
with me