Case study – Schizophrenia.

Psychological Evaluation Report

• Date: 28/03/2018
• Name: xxxxxxxxxxx
• Age: 34 years                              
• Sex: Female                                     

Socio-Demographic Details:

The client 34 years old, a Hindu female, married, Intermediate completed, hails from an urban background and belongs to middle socioeconomic status. The informant was the client and her brother. Information was adequate and reliable.

Chief Complaints were:       

Informant’s version

• Disturbed sleep
• Wandering behavior
• Talking and laughing to self

Nature of Illness                                                                           

• Onset: Insidious                                    
• Course: Continuous                     
• Progress: Deteriorating
• Duration of illness:  2year
• Predisposing factor: Nil significant as reported
• Precipitating factor: Family problems
• Perpetuating factor:  Family problems.

Brief Clinical History:

The client reported that till 2016 she was fine with her husband and after that, she started having problems with her husband as she complained that he used to beat her. The husband refused to stay with her as he doubted her fidelity

As reported by her brother two years back the client started smiling to herself, muttering to herself, and wandering away from home at night also. She was used to going to the police station to give complaints against her husband and she goes to the bus station, the railway station and spends her time there.

She was under medication for the past two years. Her husband and children started staying away from the her. Now, she started showing similar symptoms as she was not taking her medicines from some time.

20 days before the referral to the hospital, the client came to the railway station where she lost her Adhar card and failed to show identity proof to the police. From there the police caught her and admitted her into a government hospital.

Negative History:

No history suggestive of head injury or trauma, seizures or severe medical conditions, mental retardation.

Past History of Illness

• Past History of physical Illness: Nil Significant
• Past History of mental Illness: The client was under treatment for the same issues for two years before and was taking medication (irregularly).
• Family History: The client is staying with her father, mother. Her father is 58 years old, is a daily wager, the mother is 50 years old. Her husband is 40 years old and she has two children elder girl is 13 years old and the younger girl is 10 years old.

Personal History:

• Birth and developmental history: She is the second issue of non-consanguineous parents. All the developmental milestones were reported as age-appropriate
• Scholastic History: The client started schooling at the age of 5 years. She completed intermediate(+12).
• Sexual History: Not elicited
• Pre-morbid personality: The client has sociable and active she always spends her time with parents, children, and in her workplace.

Mental Status Examination:

Patient was kempt and tidy, of average height, having average body built, and appeared age appropriate. Eye to eye contact was partial. Rapport was easily established. She was attentive to the queries posed.

Psychomotor activities were at the normal limit. He spoke in a soft voice. The speech was delayed, relevant, coherent, and goal-directed. Tone, Volume, and productivity were delayed.

Abnormalities could be elicited in stream, form, and possession of thought. She was muttering sometimes and crying spells were there. No Perceptual abnormalities were elicited. Subjectively mood was reported to be “Sad”. Objectively she was having a sad mood.

She was oriented to place, time, person, day, date, month, and year. Attention was aroused but not sustained for a considerable period of time. Immediate, recent, and long-term memory were satisfactory. Abstract ability was at the concrete level. On the basis of general information, calculation, comprehension, and vocabulary she was having an average level of intellectual abilities. Test judgment was satisfactory. From history, it can be said his personal and social judgment were satisfactory. Insight was at LEVEL-I.  

Impression:

On the basis of Chief complaints, clinical history, and MSE the client is Provisionally having ICD F (20) Schizophrenia.

Suggestions:

• Refer to Psychiatry / Continue Pharmacological intervention
• Psychoeducation.
• Cognitive Behaviour Therapy 5. Relapse prevention