Case Study

CASE 4
SOCIO DEMOGRAPHIC DATA
Name : V. M
Age : 20 year
Sex : Male
Marital status : Unmarried
Religion : Hindu
Education : 9th standard
Socio economic status : Middle
Occupation : Juice maker
Residential area : Vadakara, Kozhikode
Family type : Nuclear
PRESENTING COMPLAINTS
According to the patient he came here by fighting with his neighbor and friends. He
strongly believes that some political parties betraying him.
INFORMATION
Informant : Father
Reliability of information : Reliable
Adequacy of information : Adequate
CHIEF COMPLAINTS
 Smoking
 Cannabis usage
 Usage of alcohol
 Self talking
 Destroying behavior
 Disobeying parents
 Fighting with others
Mode of onset : Gradual
Course of illness : Continues
Duration of illness : 2 years
Precipitating factor : Nil
Perpetuating factor : Nil
HISTORY OF PRESENT ILLNESS
The patient is 20 year old male living with his parents and younger sisters. From his
younger age itself he started to use drugs especially for school days onwards. When he was
studying 9th standard, there was an issue arised and thereby he was migrated his own uncle’s
house in Chennai. Then he started to help uncle’s shop and thereby he studied to making juice.
Uncle handled to deal with money and other things to patient.
Sometimes the patient is talking to self, hostile, fighting with others also. During the
time of Chennai, he started to use multiple drugs and thereby smoking also. In various situations
he was fight with uncle and leaves there and returns back into his own home. During the time of
his native place he worked as a carrier of cannabis and distributed to others including school
students. He was the only younger one in his gang. And thereby some issues arises within the
gang itself.
HISTORY OF SUBSTANCE ABUSE

During 2014 the patient started smoking with his friends. At that time he studying 9 th
standard. The friends didn’t compel him to smoke but based on patient’s interest he started that.
During that time patient was smoking occasionally then it turns into daily basis. He was used 5/6
cigarettes from a bundle of cigarette in daily basis around 6 years. Then the patient started the
usage of cannabis occasionally about one year. After that he was frequently used the cannabis up
to 3 years with his friends. In addition to that he also started alcohol usage himself. Then it turns
in to daily basis with his friends and followed by him alone. When the patient have 15 year old
he was started cannabis occasionally. When he has 16 years old he started Hans instead of
smoking. He used Hans frequently up to 2 years.
NEGATIVE HISTORY
No significant history of head injury, epilepsy, seizure, mental retardation and

neurological problems.
TREATMENT HISTORY
At first the patient took treatment from Government mental hospital, Kuthiravettam..
Currently he is under treatment of Louise Mount hospital Wayand by the supervision of Dr.
Chandran.
PERSONAL HISTORY
 Birth history : Normal

 Milestone development : Normal
 Childhood history : Normal
 Educational history
The patient started schooling at the age of 5 years old. He was average in
academic performance. Also he had a good relationship with teacher and peers.
He studied up to 9th standard
 Occupational history
He worked as a juice maker.

 Pre morbid personality
The patient couldn’t make a good relation with his family. He was in optimistic,
extraverted person. Along with he was aggressive, fighting with others and disobeying
his parents.
FAMILY HISTORY
The patient belongs to a nuclear family. He had father, mother and one young sister. His
mother was a manager in a private Bank.
MENTAL STATUS EXAMINATION
GENERAL APPEARANCE
Dressing : Normal
Cooperation : Cooperative
Eye contact : Established and maintained
Rapport : Established
Psychomotor activity : Normal
ATTENTION AND CONCENTRATION
 Digit forward
5 8
6 9 3
7 2 0 4
4 7 2 1 6
9 3 1 6 4 8
Impression: Digit forward is 6
 Digit backward
2 7
6 3 8
8 9 2 6
3 7 0 1 9
Impression: Digit backward is 4
Impression: Attention and concentration is aroused and sustained.
MEMORY
 Immediate memory
Q: Can you repeat the words I am saying?
“Book, tree, plant, theater and chair”
A: Book, plant, theater, tree, chair.
Impression: Immediate memory is intact.
 Recent memory
Q: What you had for breakfast?

A: Idly with sambar
Impression: Recent memory is intact.
 Remote memory
Q: What is your date of birth?
A: 24/02/2000
Impression: Remote memory is intact.
Impression: Memory is intact.
INTELLIGENCE
 General knowledge
Q: Who is our educational minister?
A: C. Raveendranath
Impression: General knowledge is average
 Arithmetic
 75 + 15 = 90
 647 – 247 = 400
 500 × 4 = 2000
 1000 ÷ 25 = 40
Impression: Arithmetic is average
 Comprehension
Q: What is the purpose of football net?
A: For don’t passing ball below the net.
Impression: Comprehension is average

Impression: Intelligence is average
ABSTRACT THINKING
Q: Can you differentiate between fan and bulb?
A: Both are electric devices.
Impression: Abstract thinking is functional level.
ORIENTATION
Q: What is the time right now?
A: 11.00 am.
Q: Which place is this?
A: Chennalode, Louise Mount
Q: Do you know who am I?
A: Student.
Impression: Oriented to time, place and person.
VOICE AND SPEECH
The patient’s voice is audible, coherent, non goal directed, and quick reaction time.
PERCEPTUAL DISTURBANCES
 Perceptual distortion : No illusion

 Perceptual deception : Visual hallucination
Auditory hallucination – Elementary (Hearing pigeon
sound)
THOUGHT DISTURBANCE
 Stream of thought : Accelerated (Tangentiality)

 Content of thought : Delusion of grandiose (He feels each film stories has his
own life story)
Delusion of reference (He thinks that films and news are
talking about him)
 Possession of thought : Normal
 Form of thought : Loosening association – Derailment
JUDGMENT
 Test judgment
Q: What will you do if you see a blind person want to cross a road?
A: I will help.
Impression: Test judgment is satisfactory.
 Personal judgment
Q: What will you do by living this place?
A: I will be doing smoking and work.
Impression: Personal judgment is satisfactory.
 Social judgment
Q: What will you do if you have bunch of money?
A: I will help poor people.
Impression: Social judgment is satisfactory.
Impression: Judgment is satisfactory.
MOOD AND AFFECT
Q: How you feel from last two weeks?
A: Aggressive and sadness.

Impression: Labile affect.
INSIGHT
Insight is absent.
DIAGNOSTIC FORMULATION
PROVISIONAL DIAGNOSIS
TREATMENT PLAN

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CASE 4

SOCIO DEMOGRAPHIC DATA

Marital status : Unmarried

Education : 9th standard

Socio economic status : Middle

Occupation : Juice maker

Residential area : Vadakara, Kozhikode

Family type : Nuclear

Reliability of information : Reliable

Adequacy of information : Adequate

Mode of onset : Gradual

Course of illness : Continues

Duration of illness : 2 years

Precipitating factor : Nil

Perpetuating factor : Nil

HISTORY OF PRESENT ILLNESS

HISTORY OF SUBSTANCE ABUSE

No significant history of head injury, epilepsy, seizure, mental retardation and

 Birth history : Normal

He worked as a juice maker.

MENTAL STATUS EXAMINATION

Eye contact : Established and maintained

Psychomotor activity : Normal

ATTENTION AND CONCENTRATION

Impression: Digit forward is 6

Impression: Digit backward is 4

Impression: Attention and concentration is aroused and sustained.

Q: Can you repeat the words I am saying?

“Book, tree, plant, theater and chair”

A: Book, plant, theater, tree, chair.

Impression: Immediate memory is intact.

Q: What you had for breakfast?

Impression: Recent memory is intact.

Q: What is your date of birth?

Impression: Remote memory is intact.

Impression: Memory is intact.

Q: Who is our educational minister?

Impression: General knowledge is average

Impression: Arithmetic is average

Q: What is the purpose of football net?

A: For don’t passing ball below the net.

Impression: Comprehension is average

Q: Can you differentiate between fan and bulb?

A: Both are electric devices.

Impression: Abstract thinking is functional level.

Q: What is the time right now?

Q: Which place is this?

A: Chennalode, Louise Mount

Q: Do you know who am I?

Impression: Oriented to time, place and person.

VOICE AND SPEECH

 Perceptual distortion : No illusion

 Stream of thought : Accelerated (Tangentiality)

Impression: Test judgment is satisfactory.

Q: What will you do by living this place?

A: I will be doing smoking and work.

Impression: Personal judgment is satisfactory.

Q: What will you do if you have bunch of money?

A: I will help poor people.