I.

INTRODUCTION
My patient name is mr.diwakar sahu admitted in male ward on 16/06/18 at 10:00am with
the complaint of increase talk ,decreased sleep ,decreased appetite ,violent and aggressive
behaviour and abusive behaviour ,wandering tendency and was diagnosed as a case of
mental and behavioural disorder due to use of cannabinoids (F.12.2)

IDENTIFICATION DATA
Name : Diwakar sahu
Age-35years Sex :Male
Fathers /spouse : Mr.rameshwar sahu
Address: Mahasamund (c.g.) Education: 10th
Marital status: Unmarried Religion: Hindu
Informant: Father Information: Relevant, adequate
Date of admission : 16/6/18 Registration No.7853/10
II. PRESENTING CHIEF COMPLAIN
 Self muttering
 Aggressive and assaultive behaviour
 Abusive behaviour
 Suspiciousness
 Irritability
 Irrational fear
 Wandering tendency
 Decrease sleep and appetite
III. History of present illness
 Duration
 Mode of onset
 Course
 Intensity
 Precipitating factor
History of current episode :Mr. diwakar sahu was admitted in hospital on 16june 2018 .he
was apparently well before 14 days .he become so upset and she started showing abnormal
behaviour like talked to himself ,he was behaving suspiciousness, Irritability ,Irrational
fear ,Wandering tendency .he was not able to maintain his personal hygiene ,his hair was dirty and
his cloth was cleaned .she was oriented about time ,but not orient date and place .
IV. PAST PSYCHIATRIC AND MEDICAL HISTORY
 Number of previous episode /hospitalization with onset and course :my patient is
admitted second time in the hospital .
 Complete or incomplete remission :Not significant
 Details of any precipitating factors if any :Not present
 Substance use details :cannabinoids used since 30 years
 Surgical procedure /accident /head injury /convulsion
/unconsciousness/DM/HTN/CAD /venereal disease /HIVpositivity /any other : N o

Family history

o Parent age -58 years

o Parents occupation -mother -farmer
o If expired -natural disease condition /STD – father
o Siblings -married/unmarried/occupation/school- married
o Family history of cansanguinous marriage – no
o Family medical ,psychiatric history /epilepse /neurological – not any particular
o History of family drug abuse /alcohol abuse /suicide attempt /committed suicide -no
o Home circumstances – not good
o Head of the family /leader – mother
o Current attitude of the family members towards the patient and his /her illness-not
bothered

Personal history
A. Peri natal history
 Antenatal period : not elicited
 Intranatal period : normal delivery ,not any complication was found
 Birth : Full – term
 Birth cry : Immediate
 Birth defects : No
 Post natal complication :Not present

B. Childhood history
 Primary caregiver : Mother
 Feeding : Breast feeding
 Age at weaning : 6 Month
 Developmental milestones : Normal
 Behaviour and emotional problems : Not present
 Illness during childhood : No

C. Educational history
 Age at beginning of formal education : 7 years
 Academic performance :good
 Extracurricular achievement : No
 Relationship with peers and teachers : Good
 School phobia : No
 Look for conduct disorder ,for example truancy / stealing : Not any
 Reason for termination of student : Poor socio economic status

D. Play History
 Games played at (at what stage and with whom ) : Cricket
 Relationship with playmates :Good

E. Emotional problem during adolescence : Not present

F. Puberty
 Age at appearing of secondary sexual characteristics : 15 year
 Anxiety related to puberty changes :No

G.Obstetrical history : Not significant

H.Occupatinal history
 Age at starting work :20 years
 Jobs held in chronological order :Farmer
 Reason for changes :Not significant
 Current job satisfaction : satisfied
 Whether job is appropriate to patients background : Yes
I. Sexual and marital history : Married
 Type of marriage : Arranged
 Duration of marriage :16 years
 Detail of children : 03
 Responsibility shared between spouse related to children - yes
 Relation with children : Good
 Premarital /extramarital relationship : No
 Sexual relationship – satisfactory
 Any marital disharmony – not significant
 Interpersonal and sexual relationship :Satisfactory
J. Premorbid personality
 Interpersonal relationship : Normal
 Family and social relationship : Good
 Use of leisure time :Watching T .V.
  Predominant mood :Optimistic . stable ,cheerful
 Usual reaction to stressful event :Normal
 Attitude to self and others : Normal
 Attitude to work and responsibility : Normal
 Religious beliefs and moral attitudes :Good
 Fantasy life :Not day dreaming
K. Habits
 Eating pattern : Regular
 Elimination : Regular
 Sleep : Regular
 Use of drugs ,tobacco,alcohol :alcohol ,cannabis ,tobacco etc .
Provisional diagnosis – Cannabis use ,unspecified (F.12.9)

SUMMARY
My patient Mr. bikash sahu was admitted with complains of self muttering ,aggressive
,and assaultive behaviour ,suspiciousness,irritability ,wandering tendency ,decease sleep and
appetite .The symptoms were started before 14 days prior to admission .the psychiatrist
diagnosed mental and behavioural disorder due to use of cannabinoids (F .12.9) Here drug
therapy ,ECT , and psychotherapy are given to the patient .