Topic:

Case Report

Submitted to:

Mam Anum Khan

Submitted by:

Rida Shoukat

Roll no.134

M.Sc. psychology 4th (S.S)

DEPARTMENT OF PSYCHOLOGY

UNIVERSITY OF SARGODHA
 Contents

Biodata………………………………………………03

Interview……………………………………………..03

Observations…………………………………………04

History taking……………………………………….04

Formal assessment………………………………….06

Counseling…………………………………………….07

Post assessment……………………………………….09

Questionair……………………………………………11
Identifying information

Name Zareena

Age 40 Years

Gender Female

Education Matric

Occupation Housewife

Husband Alive

Siblings 6

Birth Order 4th

Religion Islam

Marital status Married

Children 03

Father Alive

Mother Alive

Interview:

In interview with client first she says about her family and her own self and feelings. In which
including her name, age, education, parents, siblings, occupation, marriage, and city from which
she belongs. She is a house wife and she had three children. Her husband is an army man. She
lives in P.D Khan with her mother in law. She is only to take care of her house, her children, and
also her ill mother in law. She has so many responsibilities to be fulfilled alone. Her husband
comes to home after months for few days. She do all her domestic work and then take care of her
children to drop them at school and to pick them. She also did shopping alone for herself and her
children. She is alone to take care of her ill mother in law. They are not strong financially. She
says that time was too hard for her. She says that she feel found it to difficult, she became
enthusiastic and getting agitated. She is in worry about her and her family. She don’t meet people
and don’t attend social gatherings. She stay at home and feel herself alone. She has lack of
appetite. She feels restless.

Behavioral observation

Client was very cooperative during interview. Client was normal in health. She was properly
hygiene. She was proper in her dress. Her hair was properly done. She had good appearance. She
did maintain proper eye contact during interview. She was showing reluctance in giving
responses. Her behavior was good. She behaved appropriately with me. She was not much
expressive. She was quiet, her voice was not much clear and loud. She feel tired after doing little
piece of work. She thought that she was normal and she did not need any psychological
treatment.

History of present illness

Client was suffering from stress because she is only to take care of her family she had to much
burden on her and present situations due to coronavirus are an addition to her problems. She
belongs to average family system. She wants to stay at home all the time. Due to all these
reasons she shows sometime suspicious and stubborn behavior and low social interaction. She is
having feeling of worthlessness, feeling of solitude and low trust on others. She feels loneliness.

Educational History

He had done Matric. She was good in study. she is average student. She got good marks in
Matric. She also participates in co-curricular activities. She wants to continue her study. But she
became married soon after her Matric. That why she is unable to continue her study because she
has many responsibilities of her family after marriage.

Past illness History

She doesn’t have any psychological illness history. Also no one in her family have any
psychological illness history. She does not have any other illness and disorder. She does not have
any other accidental history.
Keys

F Father

M Mother

Female

Male

Normal Relation

Genogram

3S

3B

C3
Assessment

Informal assessment

Interview

Observation

Mental Status Examination

The mental status examination, abbreviated MSE, is an important part of the clinical assessment.
It is a structured way of observing and describing a client’s current state of mind, under the
domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought
content, perception, cognition, insight and judgment (Trzepacz, PT; Baker RW,1993).

Appearance:

She seemed very clean and her clothes were also very neat and clean.

Speech:

Her speech was good but voice was low.

Motor behavior:

Her general movement was slow.

General attitude:

She fully cooperated with me.

Perceptual disturbance:

She had no perceptual disturbances.

Thought content:

Her thoughts were clear.

Memory:
Her recent and remote memory was good.

Orientation:

She seemed properly oriented about time, place and person.

Drug history:

She use medicine for relaxation.

Formal Assessment

Stress – sub scale of dass. It seven items scale. Its scoring is 0-21. Its rating point is 0-3.

Quantitative interpretation

Scoring Range

Mild 0–7

Moderate 8 – 14

Severe 14 – 18

Extreme 19-21

According to the result my clients score 17 which laying in sever range.

Qualitative interpretation

In qualitative interpretation my client scores high on I become worried easily. I feel I use a lot of
nerve energy. And I feel I am too much sensitive. Client score low on I become worried about
little things. I feel my reaction is more than situation. It is hard to me to be relaxed. And late in
any situation is unbearable for me.

Counseling

In our counseling session I use some counseling techniques on my client and the re –take her
interview. Then I use post assessment. Techniques which I use are there.
Laughter

Adopting a humorous view towards life’s situations can take the edge of stressors. I suggest my
client to adopt humorous way of life. In this way her blood pressure become low and reduces
hypertension. Her cardiac condition become good. Laughter reduces neuroendocrine hormones
associated with stressor epinephrine, cortisol, dopamine and growth harmones.

Deep Breathing

I suggest her to use deep breathing technique when she feel stress. She deeply breath inhale
through your nose and as you inhale you feel your stomach expand. Slowly exhale through
pursed lips to regulate the release of air. Rest an repeat this again.

Nootropics

Nootropics are referred as smart drugs, memory enhancers, and cognitive enhancer. Nootropics
are functional foods improve mental functions such as cognition, memory, intelligence,
motivation, attention and concentration.

Fractional relaxation

I suggest her to use fractional relaxation technique in which individual release muscular tension
in one part of the body at a time.

Post Assessment

After applying stress management techniques I again ask my client to fill questionnaire again and
then I assess her present situation after applying techniques.

Informal assessment

Interview

Observation

Mental Status Examination

The mental status examination, abbreviated MSE, is an important part of the clinical assessment.
It is a structured way of observing and describing a client’s current state of mind, under the
domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought
content, perception, cognition, insight and judgment. She feel relax after applying stress
management techniques and have good health and mental condition.

Behavioral observation

After applying stress management techniques on my client I observe that her behavior is totally
change. She look relax and happy. She has good mental health and having comfortable situation.
She is not taking tension little things. She is in good mood with smiling face. She do more work
than her routine before applying stress management techniques she don’t feel fatigue and pain
after doing little work.

Formal Assessment

Stress – sub scale of dass. It seven items scale. Its scoring is 0-21. Its rating point is 0-3.

Quantitative interpretation

Scoring Range

Mild 0–7

Moderate 8 – 14

Severe 14 – 18

Extreme 19-21

According to the result before using stress management techniques the result of my clients is 18
which is laid in severe range of stress. But after applying stress management techniques on client
the post results of the client is 6 which is laying in mild range of stress. She reduces her stress
successfully.
Qualitative interpretation

After applying stress management techniques on my client I feel she reduced her stress level and
feel relax. In post assessment she scores 6 in stress scale which is laying at mild range. She is in
a good mood and comfortable with her daily routine. Now she is not worried about little things
she managed it. She doesn’t react intensively on normal reactions. She does not feel burden on
her nervous energy. She doesn’t think herself to be sensitive as she think and feel before
applying management techniques.
Stress scale

Sub scale of dass.

The rating scale is as follows.

0. = did not apply to me at all

1. = applied to me to some degree, or some of the time

2. = applied to me to a considerable degree, or a good part of time

3. = applied to me very much, or most of the time.

1 I found myself getting upset by quite trivial things. 0 1 2 3

2 I tend to over react to situations. 0 1 2 3
3 I found my self getting upset rather easily. 0 1 2 3
4 I felt that I was using a lot of nervous energy. 0 1 2 3
5 I found myself impatient when I was delayed in any 0 1 2 3
way(e.g elevator,traffic)
6 I felt that I was rather touchy 0 1 2 3
7 I found it difficult to relax. 0 1 2 3