Socio Demographic Data:
Name : HP
Age : 25
Sex : Male
Marital status : Unmarried
Religion : Muslim
Language : Kannada,urdu,hindi
Education : 6th std
Occupation : Coolie
Income : 30000
Family type : Nuclear
Family size :3
Residence : Chitradurga
Informant : Rhehena Banu ( mother) , self
Patients report:
Reliability: Reliable
Adequacy: Adequate
Chief complaints:
According to the informant:
Alcoholic consumption (since 5 yrs.)
Anger ,assaultive, aggressive ( since 5 years )
Abusive physically and verbally (since 20days)
Irrelevant talks (since 20 days)
Repetitive thoughts (since20 days.)
Self-talk and self-smile (since20 days.)
Alcohol induced Hallucination (since20 days.)
Tension ( since 20 days )
Sleeplessness and appetite reduced( since 20 days )
Suicidal thoughts ( since20 days )
History of presenting illness:
Duration: 5 years
Onset : Insidious
Course : continuous
According to the Informant:
Informant reported that the patient was alcoholic from
5 years. One year back he was treated in chitradurga. He
stopped taking medicine because of financial problem.
5 years back he was in relationship with Hindu girl for 3
years she cheated on him and married other boy. Then
patient became alcoholic. At first he used to drink
occasionally then he slowly increased his drinking
pattern. He used to drink 20 to 30 times per day.
From 20 days symptoms increased. He could not sleep if
he did not take alcohol and appetite will also get
reduced. Since from childhood he is short tempered, but
when he is drunk he shows more angriness, abusive
physically and verbally. He harm himself by cutting is
hand and neck he wants to see his own blood. He is
restless. But how much ever he drink he goes to work so
that he gets money and again drink. He speaks
repeatedly and irrelevantly when he is drunk. He gets
tensed for silly issues. He had suicidal thoughts he can
see knife on floor. He thinks other kill him.so he screams
and hides himself. He shows abnormal behaviour like
stops moving bus unnecessary and falls from upstair.He
says that he can see devils. He can see knife on floor.
Negative history:
No history of head injury.
No history of substance abuse
No history of repetitive thoughts or actions
No history of anxiety or phobias
Past illness:
Past psychiatric history – In 2018 he was treated in
chitradurga for alcohol consumption
Past physical illness – Nil
Family history:
Family of origin:
The patient was born out of non-consanguineous parents.
Patient’s father works as labour. He was alcoholic. He used
to steel money and went to jail. He separated from his
family from 20 years 4 years back he died falling from tree
and mother works as maid. He as one elder sister who is
26 and married and younger sister 24 she is blind from
birth. Patient works has labour.
Personal history:
Birth and early development:
Behaviour during childhood:
Physical illness during childhood:
Schoolings: Patient has completed his SSCL even
with his poor economic background. In academics
he was average. He was interested in kabbadi he
was champion and he trained other of his
schoolmates
Occupational : first he worked in real estate
business. He financially had lost in his business.
After few days he got delivery boy job in Zomato
Company.
Sexual history:
Marital history: he is not married yet
Pre morbid personality:
Social relations : Patient is introvert, only
speaks when spoken to
Intellectual activities : Reading newspaper and
interested playing indoor games
Mood : Patient is sensitive in nature
Character:
Attitude to work and responsibility: Patient had good
attitude towards work and responsibility
Interpersonal relationship : Patient had a very
cordial relationship with his family as well as friends.
Moral and religious standards : He is religious often
he visit temple
Energy and initiative : The patient show
normal level of energy and said that he took up
initiative to do work
Fantasy life : Nil
Habits : No habits
IMPRESSION: Premorbidly well adjusted
MENTAL STATUS EXAMINATION:
General behaviour:
General appearance : Looking once age
Touch with the surrounding : Present
Eye contact with the examiner: Present
Dress : Appropriate
Hair : Well groomed
Finger nails : Clean and tidy
Rapport : Well established
Attitude towards the examiner: Cooperative
Psychomotor activity:
Talk:
Intensity : Audible
Pitch : Normal
Reaction time : Normal
Speed : Normal
Ease of speech: Spontaneous
Relevance : Relevant
Coherence : Coherent
Goal direction : Goal directed
Productivity : Normal
Manner : Relaxed
Deviation : Nil
Speech sample:
The patient was to speak about ‘’namaz’’
‘’.’’
VOILATION: Present
MOOD AND AFFECT:
When asked how he has been feeling in the past few
days. The patient reported ‘’”.
Affect: Patients expression was sad and voice was
low.
IMPRESSION: Mood congruent affect
THOUGHT:
Thought stream : No flight of ideas,
retarded thinking, thought blocking was absent
Thought possession : No obsessions and
compulsion was present, no thought alienation
Formal thought disorder: Absent
Thought content : Ideas of guilt present.
IMPRESSION: Thought content was impaired
Perception : no perceptual disturbance present
Cognitive status:
Attention and concentration:
The patient was asked to repeat digit forward and
backward
He was able to repeat three digits forward and
digits backward.
He was able to subtract 100-7,90-8 and 75-25
immediately
He was able to say months of the year and week
days backwards.
IMPRESSION: Attention and Concentration was
normally sustained
Orientation:
Time : Patient was able to tell the approximate
time
Place : Patient was able to say the name of the
hospital along with the place it is located
Person: Patient was able to name the examiner
as doctor
IMPRESSION: Oriented to person, place and time
Memory:
Immediate memory: Patient was asked to say
colour of dress which cleaning staff was wearing.
He was able to say it correctly.
Recent memory : Patient was able to recall the
breakfast he had that day morning and previous
day night. It was checked with his mother.
Remote memory : Patient was able to say his. It
was confirmed with his mother.
IMPRESSION: Immediate, recent, remote memory is
intact.
Intelligence:
General formation:
The patient was able to say prime minister of India
and chief minister of Karnataka.
Comprehension:
When asked, ’’ what will you do when it’s raining
when you are walking on road ‘’
He said, ’’ I will walk in rain ’’
When asked, ’’What will you do when your house
key is lost’’?
He said, ‘’I will think where I kept before and I will
search for it’’
Calculation:
The patient was asked if,’’ If you buy 5 books cost
of Rs.30. what is the total bill you should pay for
shopkeeper?
He said,’’150 rupees I should pay him’’ replied
immediately.
IMPRESSION: average intelligence
Abstract ability:
When he asked to tell the meaning of the
proverb,’’chinthe eladavinge santhe alu nide’’
He said, ‘’A man without worries can even sleep
in market’’
When he asked to tell the meaning of the
proverb,’’Adikege hoda mana anne kotru barolla’’
He said, ‘’Once respect is gone it cannot be
regained’’
When he asked to tell the meaning of the
proverb, ’Prathyakshavagi kandaru pramanisi
nodu’’
He said, ’’We should think before we judge’’
The patient was able to say the difference and
similarities between and he said shape and
colour is somewhat similar but apple is sweet in
taste and tomato is sour; carrot and radish- he
said both are vegetables same shape and
difference is colour carrot is orange and taste
sweet and radish is white and spicy taste.
IMPRESSION: Abstract level of thinking
Judgement:
Personal: when asked what his plans after the
discharged from hospital, the patient said the
following ‘’ ‘’
Social: The patient’s social relationship was less.
Because he was depressed of his illness and he
don’t want to speak with anyone. During the
sessions he was cooperative and well-spoken to
examiner.
Test:
When asked, ‘’ what would patient do if stamped,
sealed, addressed envelope is found on the
street? ‘’
He said, ‘ I don’t know to read I will give to
someone who can read’’
When asked, ‘’ what would you do if you found a
child playing near a well?’’
He said, ‘’ I will pull child from the well ’’
When asked, ‘’ what would you do if the house
caught fire?’’
He said, ‘’ I will put water.’’
IMPRESSION: Personal and test judgement intact
where as social judgement is impaired
Insight:
Grade
Test administered:
Rationale for administering the test :
Test findings:
Diagnostic formulation:
Provisional Diagnosis :
Axis I:
Axis II – Disability Diagnostic Scale, DDS
a) Personal care and survival –
b) Occupational functioning –
c) Family functioning –
d) Functioning in a broader social context –
Axis III – Environmental/ circumstantial and
personal lifestyle management factor
Good prognostic factor
• Insight into the problem
• Premorbidly well adjusted
• Supportive mother
Poor Prognostic factor:
•
