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Case History

a sample case history that can be used as reference for taking case history or understanding how to write down case history

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aananyaa2020
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39 views3 pages

Case History

a sample case history that can be used as reference for taking case history or understanding how to write down case history

Uploaded by

aananyaa2020
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE STUDY FORMAT

CASE HISTORY

IDENTIFICATION & SOCIODEMOGRAPHIC DETAILS


NAME: K.A

AGE: 14 years

GENDER: Male

EDUCATION: Studying in class 8

OCCUPATION: Student

MOTHER TONGUE: Hindi

MARITAL STATUS: Unmarried

CHIEF COMPLAINTS:

 Parental pressure
 Poor performance in academics For past 3 months
 Low mood

HISTORY OF PRESENTING ILLNESS: The client is having parental pressure


mainly for his academics from past 3 months. He achieved poor grades in all
the subjects in his half yearly exams. Since then he is not allowed to use mobile
phones and talk to his friends. He is also having mood fluctuations. He also has
clashes with his parents and remains unhappy most of the times. His parents
do not understand his feelings and always force him to do things which they
like.
PAST MEDICAL HISTORY: History of seizures

TREATMENT HISTORY: The client was on medication for seizures.

PERSONAL HISTORY

BIRTH HISTORY: The client is a full term delivered child through normal
delivery. His immediate birth cry was present. Birth weight was reported to be
average. There is no history of any head injury.

FAMILY HISTORY: The client lives in a joint family with his grandparents,
parents, elder brother, uncle and aunt. He belonged to a middle-class family.
His father is a van driver and his mother is a housewife. The family
environment as described by the client is inappropriate as there are disputes in
the family. The client has good bonding with his grandmother. There is no
history of any mental instability in the family members.

SOCIAL HISTORY: All developmental milestones of the client were reported to


be age appropriate. He was a good student but his academic performance is
gradually getting worse. He had a good relationship with his friends. He had
physically aggressive behaviors. He loved to play online games with his friends.

MENTAL STATUS EXAMINATION


GENERAL APPEARANCE AND BEHAVIOUR:
The client was well groomed and neatly dressed. He sat on the couch with
appropriate body posture. Rapport was well established with the client. He
was cooperative to the clinician during the entire session.

EYE CONTACT: The client maintained eye contact with the clinician.
PSYCHOMOTOR ACTIVITY: His motor activity was within normal limits.

SPEECH: His speech was audible, fluent and spontaneous with normal reaction
time. It was relevant, coherent and goal directed.

MOOD AND AFFECT: His subjective mood was reported as “Very unhappy”.
The objective affect was observed to be depressed. It was stable and
appropriate to the situation and congruent with his stated mood.

THOUGHT: No abnormality detected.

COGNITIVE FUNCTIONS:
ATTENTION AND CONCENTRATION: the client was alert and conscious. The
attention was easily aroused and sustained.

ORIENTATION: The client is oriented to time, date, month, year, person and
place.

INTELLIGENCE: His intellectual functioning was found to be average.

ABSTRACTING ABILITY: His abstraction ability, as demonstrated by discussing


the meaning of certain proverbs, was intact.

INSIGHT AND JUDGEMENT: The client was aware of the current issues he has
been facing. His judgement was intact. He wants to be helped and was
cooperate with the clinician.

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