CASE HISTORY REPORT

Submitted To:
Ma’am Nimra Bashir Cheema
Submitted By:
Aleesha Iman
Roll# 231520026
BS Clinical Psychology-1

DEPARTMENT OF CLINICAL PSYCHOLOGY

FACULTY OF HUMANITIES AND SOCIAL SCIENCES, GIFT
UNIVERSITY, GUJRANWALA.
Introduction
This is the case history which I am submitting as part of my course requirement. This
report discusses the case of Mr. A who is 20 years old boy. This report discusses the presenting
complaints and a brief history of client.

Demographics
Name Mr. A
Sex Male
Age 20 years
Education F.Sc
No. of siblings 3 (1 brother, 2 sisters)
Birth order 3rd

Religion Islam
Informant Himself and case files
Marital status Single
Address Gujranwala

Context and reason for referral

This case report is about a young boy, Mr. A, who 20 years old. He is unmarried and
belongs to an upper-class locality of Gujranwala. He was brought to hospital on account of mood
swings and anxiety. Information related to case was obtained from client himself and he was
considered an incredible historian; additional information was verified from his case files.
Client had not been coming to psychiatric treatment.

Assessment Process
This section discusses the mental status of the client and any psychological testing that
has been done on the client.
Mental Status Examination
Mr. A was a young boy of fair complexion who appeared to be his stated chronological
age of 20 years. He had a small height and thin body built. During assessment process, he was
dressed in neat and clean traditional clothes. He was looking alert during interview and no
prominent physical abnormalities were observed in client. He maintained a good eye contact
during whole assessment process. Client’s attitude towards interviewer was very cooperative.
Client’s rate of speech was appropriate. There were articulations, his volume was soft and the
content of speech was fluent. His affect was of full range and stable during the whole assessment
process. His thought process was logical and no restrictions in stream of thoughts were reported.
During the assessment process, there were no signs of psychomotor agitation and retardation or
history of presentation of hallucinations, delusions and obsessive-compulsive thoughts. He was
known to time, person and place. His level of consciousness was alert. He has good memory
also.

Presenting Complaints
According to client, he had following complaints, for over a week:

 Overthinking
 Show low mood
 Loss of pleasure and interest in daily life activities
 Feelings of guilt

History of Presenting Complaints

Client came to the hospital for treatment because he had overthinking due to major stress.
He stress about his future. He has fear of failure. That’s why he thinks over.

Risk Assessment
Risk assessment was conducted with the client. Based on the information received by
client during interview, it is concluded that the client was low on risk assessment because he
reported no suicidal and homicidal ideations or risk from others.

History of Prior Illness

Mr. A was good during his matriculation and his F.Sc. When client completes his F.Sc he
ill with some breathing issues. Then he was giving English language test for international student
visa. He was fail in test. That’s the reason he had overthinking.

Background History
This section explains the history of client.
Family History
Mr. A belongs to an upper-class family of Gujranwala. He lives with his family. There
are 5 members in his family including her mother, father, and two sisters.
Client’s father is a 55 years old man who used to work in an import and export business.
As reported by client, her relationship with his father is similar because he and his father both
have short tempers and they tend to fight or argue over small matters. However, over the past
few months their relationship with father not so good due to the bad results in test. The reason
might be the persistent low mood of client made his father more concerned about his.
Her mother is 50 years old, who worked as a housewife. According to client, his
relationship with his mother used to be okay. He sometimes had arguments with her mother too.
He found her mother more supportive as compared to her father in certain matters.
Client’s has 2 sisters. Both of Sisters are elder than client. One of the client elder’s sister
was married.
Birth and Developmental History
Mr. A reported that he had a normal birth without any pre or post term complications and
he achieved her developmental milestones with appropriate age range.
According to client, within his immediate and extended family, he was loved and
pampered and had close relationship with her elder cousins and other family members because
he was the youngest child of his family. He said that always got whatever he wanted. He was an
average child, he made friends easily. Although after school he did not keep in touch with them.
He only had one friend close friend until fifth grade. He was his neighbor.

Educational History
Mr. A started his formal education at the usual age of 5 years. He was enrolled in Lahore
Grammar School. Both his elder siblings also studied at the same school and then graduated with
excellence. Client reported that his performance during middle and elementary school was
satisfactory. He also reported that he had a very enjoyable and good time in school and made
friends within and outside his class and felt safe within school environment. But when he
completes his F.S.c he appearing in Language test and then unluckly he was not passed the test
then he has fear of failure and stressing about future.

Marital and Romantic History

Client has not reported history of his romantic relationships.
Sexual History
Mr. A is aware of sex and has read about it over the internet and books. But he has not
experience.
Medical History
When client has some breathing issues then takes some appointment.
Psychiatric History
Client’s father has a history of overthinking and anxiety. He gets angry over small
matters. He is also under psychiatric treatment for anxiety.
Client also reported history of his psychiatric treatment of anxiety.
Drug History
Client reported that he was taking mood stabilizers and some prescribed by his doctor but
he never abused any drug.

Premorbid Personality
 Before the course of illness, the client had been reported as a friendly person. Although
he had a few close friends outside his family, he was very active on social media.