CASE STUDY- 2

HISTORY

A. Name :T
B. Age : 17
C. Sex : Female
D. Socio-economic status : Middle-class family
E. Locality : Urban
F. Informant : Mother of Patient ( Adequate, reliable and consistent )
G. Complaints : i) Frequent headaches
ii) Irregular sleep cycle
iii) Lack of coordination and clarity
iv) Can hear unknown voices
H. History of present illness
The onset of the symptoms has been phased, for the past 5 times. The case has been given
treatment in various hospitals and got admitted lately due to her irregular sleep cycle and lack
of focus on her day-to-day conditioning.

The pouring events might have been her resuming going to school regularly in person after a
long break with online classes continuously. She has not been capable to concentrate rightly in
her classes. She frequently finds it hard to concentrate and isn't competent to comprehend the
classes taken. She substantially ends up sleeping in class due to a lack of sleep at night.

The course of the illness is 5 times in 2017. additional information wasn't available due to a
lack of mindfulness by the parents.

The informant says the patient hears an unknown manly voice. The voice asks her to go away,
constantly. She's frequently lost in deep thoughts and wishes to be alone. She's basically
distorted from her surroundings.

Around the same time, she was passing through her adolescence and her parents frequently
mistook this as similar changes. During a several incidents, she ran up to the terrace alone. She
locked herself in the house sending both her parents out.

And she demanded serious social interaction around this time and preferred to stay in her
room filled with her thoughts. She faced a lot of lack of coordination and was blank

The informant said that the patient complained of hearing unknown voices of a man, but
originally, the parents didn’t pay heed, latterly on, her malformed behaviour prevailed for over
 a time. So in 2018, the patient was taken to the doctor for hallucinations and lack of sleep. She
was given tablets for it.

Upon consuming tablets, the patient had bettered sleep. But soon with offline classes starting
the patient wasn't capable to concentrate on in- person classes, and ended up sleeping in the
classroom daily. This soon affected her marks and lowered her overall performance.
Her marks slipped down indeed further and she lacked sleep during the night. And she
frequently felt someone walking on the terrace. She sluggishly turned paranoid about the
people around her.

I. FAMILY HISTORY

Father- 48 years old, Breadwinner of the family, works as Civil Engineer.

Mother-42 years old, Housewife

Father takes most of the decisions. Took some time to accept patient’s illness.
Mother takes care of the patient.

J. PERSONAL HISTORY
1. Birth: There were no complications during birth, Normal delivery.
2. Childhood: Enthusiastic and brisk. Milestones: Normal
3. Schooling: The patient is a moderately performing school girl.
4. Work: Not working
5. Menstrual History: The menstrual cycle is regular in the patient.
 6. Sexual History: Could not be elicited.
7. Marital History: Unmarried
8. Substance Use: No use of any kind of substance.

K. PREMORBID PERSONALITY
1. Social Relations: The patients relation with relatives is good and she is close with her
family.
2. Intellectual Activities: The patient doesn’t have any specific activities or interests other
than listening to music.
3. Mood: Silent, Confused, Inactive
4. Character: Behavioral instability and impulsiveness, likes to be lonely with her thoughts.
5. Energy: Inactive, Lazy
6. Fantasy life: Loves to be at home and watch movies.
7. Habits: No harmful habits found, was good and normal.

MENTAL STATUS EXAMINATION

A. General Behaviour
The patient is loner with her thoughts and hears the voice of a man. She listens to music
but couldn’t concentrate in her academics.

B. Psychomotor Activity
The patient responded slowly to most of the questions. She couldn’t perceive and was
sluggish in answering the questions, even her volume and tone of speech was lower.

C. Speech
The patient had clarity in her speech however; her rate of speech was decreased.

D. Thought
Had clear thoughts and had no formal thought disorders.

E. Mood
Loves to be alone and responded after some time to the questions.
Subjective: Normal, stable
Objectively: Tensed

F. Cognitive Functions
 i) Orientation
Patient was able to tell the correct date time and place.

ii) Attention and Concentration

Patient concentrated throughout the session and was able to focus and respond.

iii) Serial Subtractions

Took time to recollect but was able to answer for 20-1.

iv) Memory
The patient has intact memory and was able to recollect the events of past 24 hous and
her address correctly.

v) Intelligence
1. General Intelligence: Intact
Answered current events and name of the prime minister correctly.

2. Comprehension: Average
Patient responded that she would use a bed sheet and umbrella when it is cold and
rains respectively.

3. Arithmetic: Poor
Her answer was 8 when the question of “if the cost of one pen is 25 paise, then
how many pens will you get for 2 rupees?” was asked.

4. Abstraction: Poor
She was able to identify grapes and orange as fruits, and was able to differentiate
between a stone and a potato by rationalizing that a potato is edible.

5. Judgement:

Personal Judgement: While asking what she would do once she goes out, she answered
she will attend her school as usual.

Test Judgement: When she sees an unposted letter, she will pick it up and post it.

Social Judgement: She said when a house is seen with fire, she’d help the people or try
to call for help.

SUMMARY
A young girl studying higher secondary school from a middle class semi urban background
presented with complaints of insomnia, hallucinations and lack of coordination in her day-to-day
activities and got admitted.

Believes that someone was walking on the terrace

Had hallucination of hearing a man’s voice
Decreased activities
Lack of social interaction

On reports of MSE,
General behaviour was that she was well dressed, completely conscious, relaxed, maintained
hygiene and was disoriented occasionally. Her speech was applicable and coherent. The major
mood was anxious with oscillations in it. She substantially hallucinated a man’s voice saying,
‘Podi’. She feels someone is walking up in her terrace. In cognitive Functions, she was handed
with test. The patient is veritably poor in introductory computation operations. But had good
memory and mindfulness.

Diagnosis: The patient is diagnosed with Paranoid Schizophrenia.(According to ICD 10, DSM
5)

MANAGEMENT

Psychoeducation-Family counselling
Pharmacotherapy-Antipsychotics
Cognitive behavior therapy
Supportive therapy