Propose a provisional diagnosis of the below and provide a case history too in a

format.

CASE 1

A 40 years old school teacher attends his general surgery with his wife complaints
of feeling constantly fearful and stressed. These feeling have been present on
most days over the past 3 years and are not limited to specific situations or
discrete periods. He also experience poor concentration, irritability, tremors,
palpitations, dizziness and dry mouth. He has continued to work, but his
symptoms are causing stress at work and at home. He denies any problem with
his sleep. He finds it difficult to fall asleep and states that does not feel refreshed
on waking up. He has been married for 15 years and lives with his wife and 2 sons
aged 8 and 10. His parents live locally and he has no sibling. His father has been
diagnosed with Alzheimer’s dementia. He remembers his mother being anxious
for much of his childhood. He has no previous medical or psychiatric history and is
not taking any medication. He smokes 20 cigarettes per day and drinks alcohol
socially. He has never used any illicit drugs. He tends to hide his symptoms and
said that he was seeing his general practitioners because his wife wants to seek
help.

Mental state examination-

He makes fleeting eye contact. He is a neatly dressed man with no evidence of

self neglect. He appears to be restless and tense but settles down as the interview
progresses. He answers all questions appropriately and there is no abnormality in
his speech. His mood is euthymic and he does not have thought of self harm.
There is no evidence of delusions or hallucinations. He is able to recognize the
impact of his symptoms on his social and occupational functioning is keen to seek
help.

Physical examination

His blood pressure is 140/90 mm Hg and his pulse is regular and 110 beats per
minute. The rest of the physical examination does not reveal any abnormality.
Provisional Diagnosis –

The teacher is suffering from Generalised Anxiety Disorder (GAD). His predominant feeling as
mentioned is constantly fearful and stressed due to prevailing insecurity. He also has tremors,
palpitation and dry mouth indicating autonomic arousal anxiety, as these symptoms are present
for more than six months (almost for three years). His physical examination indicates higher BP
and pulse rate. He finds difficulty in sleeping and does not feel fresh when waking up indicating
disturbed sleep pattern. Also the symptoms are not limited to specific situations or discrete
periods discounting other anxiety disorders like social phobia, specific phobia, PTSD and OCD.

The information furnished is limited and we may need to do detailed case history and MSE.
Certain medical tests like blood sugar, thyroid functionality may help in ruling out effects of
physical illness.

Initial stages of GAD can be dealt through counselling. Moderate stage of GAD may need CBT
and severe chronic cases may need medical intervention.

CASE HISTORY –

IDENTIFICATION DATA -
Name – XYZ
Father’s/Husband name - XYZ
Age – 40 yrs
Gender - male
Marital status – Married
Education – unknown
Occupation – Teacher
Income - nil
Religion – unknown
Address – XYZ
Phone no. - XYZ
Email – XYZ
PRESENT CHIEF COMPLAINTS –
Constant feeling of fear and stress, on most days for more than three years. He also experience poor
concentration, irritability, tremors, palpitations, dizziness and dry mouth.
HISTORY OF PRESENT ILLNESS -
Onset – Since three years
Duration – three years
Suddenly/gradually - gradually
Precipitating factors – Mother was anxiety patient
When the patient was last well – till three years ago.
Patient’s life circumstances at the onset of symptoms or behaviour changes – Nothing specific
PAST ILLNESS –
Psychiatric – nil
Medical – Nil
Alcohol and other substance abuse – Smokes 20 cigarettes per day and drinks in social gatherings
(occasional)
FAMILY HISTORY –
Family structure
 Family history of illness – Father is suffering from Alzhimer’s decease, and mother has anxiety
disorder..
Major medical illness - nil
Current social situation - His symptoms are causing stress at work and at home.
PERSONAL HISTORY – we need to take more information for detailed case history.
a) Perinatal / prenatal / postnatal history
Perinatal history –
Prenatal –
Physical / psychiatric illness –
trauma to abdomen-
Medication / drug / Alcohol use –
Immunisation –
Birth –
Full term / premature / post-mature
Wanted / Unwanted
Delivery –
Normal / Instrumental / Caesarean
Birth cry –
Immediate / delayed
Birth defects – nil,
Any other - nil
b) Childhood history
Primary caregiver – whether the patient was brought up by mother or someone else - Mother
Feeding – Breast feeding / Artificial
Development milestones – Normal / delayed
Age & ease of toilet training – easily trained by age of 2yrs
Behavioral and emotional problems –
Thumb sucking -
Temper tantrums -
Phobias –
Nail biting -
C) Educational history –
Age of beginning and finishing formal education –
Relationship with peers and teachers-
Any school phobia -
Any learning disability -
Termination of studies –
d) Devotional problem during adolescence
Relationship history with peers, particularly the opposite sex -
Any emotional trauma at adolescence –
Relationship with parents –
 Play history -
e) Puberty –
Any anxiety related to change in puberty -
Masturbation -
f) Menstrual and obstetric history –
Regularity and duration of menses -
Length of each cycle -
Any abnormalities –
The last menstrual period –
No. of children born –
Termination of pregnancy –
g) Occupational history –
The age at starting work –
Job satisfaction –
Ambitions –
Relationships with authorities, peers, subordinates –
Present income –
Job is appropriate to the educational and family background –
h) Sexual and marital history -
Sexual information –
Premarital & extra marital sexual relationship –
Sexual practices (normal & abnormal)-
Sexual satisfaction –
Duration of marriage –
Arranged marriage by parents with or without consent –
Number of marriage –
Divorces or separations –
i) Premorbid personality –
Interpersonal relationship -
Use of leisure time –
Predominant mood –
Attitude to self and others –
Attitude to work and responsibility -
Religious belief and moral attitudes –
Fantasy life-
Habits –
j) Alcohol and substance history – NIL
Alcohol history : Duration- / Degree – / Withdrawal symptoms –
Substance history – Duration- / Degree – / Withdrawal symptoms –