PSYCHIATRY HISTORY AND EVALUATION

Assessment by : ANANYA S M

SOCIO DEMOGRAPHIC DATA

1. NAME: Ramya
2. PARENTS NAME: Nagesh (F), Usha (M).
3. ADDRESS : Hanumantha pura ,
Holehonnuru,
Bhadravathi.
Phone No: 8496968954

C/O ADDRESS : Fire Engine Quarters,

Near Bus Stand,
Shivamogga.

4. AGE: 11 Years
5. SEX : Female
6. LANGUAGE : Kannada (MT), English.
7. EDUCATION: 6th Standard
8. INCOME OF THE FAMILY: BPL
9. RELIGION : Hindu (Kuruba)

REFERAL DETAILS: Relative.

INFORMANT: Mother and Self.

INFORMATION: Reliable.

NEEDS FURTHER PROBING: Yes.

PRESENTING COMPLAINTS: DURATION: Since Early Childhood

1. Displays intense anger. SEVERE: Since 2-3 years

2. Lies often.
3. Do not accepts her mistakes.
4. Uses abusive words and hits parents.
5. Behaves like an adult.
6. Gives much importance to makeup and her appearance / highly beauty conscious.
7. Shows interest in watching T.V serials.
8. Food intake is low.
9. Low socialization.

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 10. Very stubborn.
11. Over thinks about others opinion on her.
12. Low performance in academics.

HISTORY OF PRESENT ILLNESS:

Client’s mother reported that client is much conscious about her beauty. She spends long hours in front
of mirror, even when she is getting late to school she keep insisting on her hair style to be perfect. She
constantly compares herself with others. She keep asking for new dresses.

She displays stubbornness and anger when things are not on her way. She lies often and doesn’t accepts
her mistakes. She uses abusive words and hits her parents . When she was in class 3 or 4 she used to be
alone and didn’t mingle with her peers. But now socialization has improved .

She behaves more like an adult. She shows much interest in watching serials and playing games in cell
phone. She has been taken to hospital as she eats less and she refused to take medicines given by the
doctor. She keep asking for snacks.

She is good at extracurricular activities like dancing and singing. She performs poorly in academics. As
per her teacher says she do not concentrate in class, do not mingle with boys and scores poorly in tests.

PAST HISTORY:

Client was kept in current for the first five days after delivery as she had drank faeces water.

Had fits attack once when client was 2 years old and she was treated in Nanjappa Hospital, Shimogga.

Once she was bit by the street dog and she was given necessary treatment.

FAMILY HISTORY:

Client hails from low economic background family. Her father name is Nagesh, he is a farmer. He is
uneducated. He drinks alcohol and consumes gutka. He restricts client to mingle with others. Client’s
mother name is Usha. She is a tailor and she has studied till 10 th standard. Their marriage is
consanguineous marriage. The first fetus was aborted as it was dead in the womb. Client has 2 year old
younger sister. Client lives in a nuclear family.

The relationship between husband and wife is not so good as he suspects his wife. They fight in front of
children. Father uses abusive words.

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The family history of illness is present. Client’s paternal grandmother , father’s sister and maternal great
grandmother and mother’s aunt had some psychological issues.

PERSONAL HISTORY:

During antenatal period mother was very sad and couldn’t take good nutritious food as her husband
suspected if it was his baby. After 7 months she moved to her mother’s home. It was caesarean birth.
Birth weight was 2kg 5 grams. Client was kept in current for the first five days after delivery as she had
drank feces water. Immunization has been given. Developmental milestones (speech, sitting, standing) is
normal that is within one year. Client has been breast fed for one and half years. Childhood health was
normal. Twice client has told her mother in anger that she will commit suicide.

EDUCATIONAL HISTORY:

Client was sent to school when she was 4 years old in one year she completed both LKG and UKG. LKG to
2nd standard she studied in one school later she changed school because her parents wanted her to
study in English medium school. Her teacher complaints for her lack of concentration and poor academic
performance in school.

MENTAL STATUS EXAMINATION:

GENERAL APPEARANCE AND BEHAVIOUR:

1. APPEARANCE: Appropriate.
2. LEVEL OF GROMING: Normal.
3. LEVEL OF CLEANLINESS: Adequate.
4. LEVEL OF CONSCIOUSNESS: Fully conscious.
5. MODE OF ENTRY: Came willingly.
6. COOPERATIVENESS: Normal.
7. EYE-TO-EYE CONTACT: Maintained.
8. PSYCHOMOTOR ACTIVITY: Normal
9. EMPATHY: Spontaneous.
10. QUALITY OF RAPPORT: Good.
11. GESTURING: Normal.
12. POSTURING: Normal.
13. OTHER MOVEMENTS: Not present
14. OTHER CATATONIC PHENOMENON: Not present.

SPEECH:

1. INITIATION: Spontaneous.
2. REACTION TIME: Normal.
3. SPEED: Normal.
4. OUT PUT: Normal.

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 5. PRESSURE OF SPEECH: Present.
6. VOLUME: Normal.
7. TONE: Norma.
8. MANNER: Normal.
9. RELEVANCE: Fully relevant.
10. STREAM: Normal.
11. COHERENCE: Fully coherent.

THOUGHT: Content.

MOOD: Subjectively and objectively cheerful.

PEREPTION: No hallucinations present.

COGNITIVE FUNCTIONS:

1. ATTENTION: Normally aroused.

 DIGIT FORWARD: 2,3,4
 DIGIT BACKWARD:2 ,3
2. CNCENTRATION: Normally sustained.
 Can tell weeks backward and forward.

3. ORIENTATION:
 TIME: Present
 PLACE: Present
 PERSON: Present
4. MEMORY:
 IMMEDIATE: Intact
 RECENT: Intact
 REMOTE: Intact
5. INTELLIGENCE:
 COMPREHENSION: Appropriate
 VOCABULARY: Good
 GENERAL FUND OF INFORMATION: Good
 ARITHMTIC ABILITY: did not ask
 ABSTRACTION: Normal
 JUDGEMENT: Intact

INSIGHT: Present.

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SUMMARY AND EVALUATION:

Ms. Ramya came with complaints such as Displays intense anger, Lies often, Do not accepts her
mistakes, Uses abusive words and hits parents, Behaves like an adult, Gives much importance to
makeup and her appearance / highly beauty conscious, Shows interest in watching T.V serials. It can be
understood that client’s environment, family atmosphere, parenting style and television might have
influenced the client to behave so. This can be diagnosed as CHILDHOOD CONDUCT DISORDER, requiring
counseling.

PLAN OF ACTION:

 Family counseling
 Teaching behavior modification techniques to mother
 Counseling to client.