PSYCHIATRY WARD HISTORY

Demographic Details
Mr. Mamoon ur Rashid, 38 years old male, married 15 years ago,
educated till 7th grade, employed as a laborer and resident of
Barakahu .
Reason for Referral
Patient was brought to the OPD department of IOP by his will and was
admitted in IOP 5 days ago.
Referral Source
None
Informants
The patient himself
Presenting Complaints
Depression and Stress for 5 years
Verbal and Physical Aggression for 5 years

Patients Verbatim

History of Present Illness

Patient is a known case of depressive illness for last 5 years. His
illness is sudden in onset and intermittent in nature. It is however
his first admission in the IOP. Currently he presented with 4 months
history of physical and verbal aggression towards his family members-
both provoked and unprovoked. He used to hit his family members with
everything that came in his hands therefore as much as possible sharp
objects were kept out of his reach. He also presented with a headache
for 5 years that have aggravated over the years, headache is sudden
in onset and mostly occurs on one site, with severe in intensity, he
takes no medicine to relieve the pain. There is history of running
away from home several times, and going to the graveyard. At work
place he feels insecure as if his wife is cheating on him, he states
that he gets this feeling from within himself. There is active
homicidal ideation and he has attempted homicidal attacks several
times on every person that does something that makes him angry. He
has history of experiencing déjà vu at several instances in his life.
His biological functions are slightly disturbed. He finds difficulty
in sleeping for 5 years, with sleeping only 2 hours daily. His
appetite is normal, and there is no weight loss or any change in
excretory habit reported.
Treatment History
Patient has not taken any ECT therapy
Medications

Patient was compliant to the medical therapy

Side effects

Past treatment taken by Moulvi and Dam Darood was used to reduce his
symptoms 5 years back
He consulted with a psychiatrist at Akbar Niazi Hospital who gave him
medication to alleviate his symptoms.

Past Psychiatric History

He consulted with a psychiatrist at Akbar Niazi Hospital who gave him
medication to alleviate his symptoms. However after his Father’s
death 5 years ago he has been suffering on and off with various
episodes of insomnia and aggressive behavior.

Medical and Surgical History

No history of any head injury, accident or hospitalization.
No history of any chronic illness like Diabetes mellitus, asthma, TB

Family History
Father died a natural death at the age of 75 and the patient was
deeply moved by the incident
Mother 49 years old housewife
It was a consangious marriage between the parents
There is poor interpersonal relationship between the patient and her
mother
They are 8 siblings in total all are married
There is a family history of his sister having a traumatic head
injury which led to some behavioral changes.
His relationship with wife is not good, they both often indulge in
quarrels several times over useless things.
He has 5 daughters and for 5 years his relationship with them is not
good, he beats them and abuses them.
His family members do not do any sort of drug abuse

PERSONAL HISTORY
Birth and Early Development
Patient was born after 11 months of pregnancy
There were post-natal complications in the infant his blood vessel at
the forehead was very visible and it was difficult for him to survive
Milestones were achieved at appropriate times.

Schooling
He started his schooling at 5 years of age in his village in Murree.
He was an average student and his performance in school was an
average one.
He studied till 7th grade.
He did not attend the school regularly he used to leave from home for
school but instead used to go to play with friends.

Adolescence
He reached puberty at 14 years of age. He started smoking under the
influence of his friends in 1998 and since then he used to smoke one
or two packs of smoke daily. He also started Naswar in 2003 under the
influence of his friends.

Occupation
Patient has adapted almost every occupation from goldsmith, mobile
shop owner, sold milk, yogurt, set up a stall at Landa Bazaar, sofa
polish, worked in a hotel and in the end he worked as a laborer, he
had no specific reason to leave any job, he just felt he was losing
interest in one thing and therefore started off with another job. But
he is unemployed for 5 years now.

Psychosexual History
Patient denied to provide any information.

Marital Status
Patient is married to the daughter of his fraternal uncle, it is a
consanguineous marriage between the two. It is a love marriage from
the wife’s side however he was not willing for the marriage, but
because father said so he had to do it.
Drug History
Smoking for 18 years 2 packs
Naswar for 15 year upon pressure by friends
Patient intents to give up smoking and he is trying.

Forensic History
No history

Socioeconomic status
The family members, husband wife and their 5 daughters live together
in patient’s brother’s house, the house is adequate for the family
members. The economic status is average. The source of income is his
brother.
Relationship of the patient with neighbors is an aggressive one and
patient has been a part of many fights.

Premorbid Personality
Before illness he was not as aggressive and he was caring and loving.
He was very attached with his father and his death left him in a
great shock.

Mental state Examination

Appearance:
A young man looked according to his stated age, average height, thin
built he sat comfortably with no signs of psychomotor agitation. He
was dressed appropriately according to culture and weather. His
replies were relevant and coherent. Eye contact was made and
maintained through out.
Rapport was established easily.

Mood

Talk
He talks with normal rate and rhythm.

Thought
He has developed very pessimistic
Perception
Auditory hallucinations that are commanding in nature. Every type of
hallucination is present from tactile, to auditory, visual,
gustatory.

Orientatiion
He was well orientated to time and space.

Registration 4/5
Recall 3/4
Short term memory intact
Long term memory intact
Abstract thinking intact
Judgement intact
Insight intact