Hospital Nayi Zindgi: Case # 1 Patient History

CASE # 1
Patient History
Hospital NAYI ZINDGI

BIODATA
Name: S.A
Age: 33 years
Gender: Male
Education: Primary school
Marital status: Married
Religion: Islam
Siblings: 6 (4 brothers,2 sisters)
Birth order: 4th
Residence: KASHMORR
INFORMANT:
His brother in law brought him to the hospital.
REASON FOR REFEREL:

The client explained that he had sleep problems and he felt that his body had more energy
than usual routine because of the use of drugs. Then he also started drugs and his condition
became worsen then he flew off from home then he came to Multan where his brother in law
brought him to the hospital for treatment.
PRESENTED COMPLAINTS:
According to the client,
He had no complaints for his family members.
He said he had some complaints about this hospital like,
Other patients are cruel and not cooperative.
Doctor don’t pay heed to me.
I feel loneliness here.

HISTORY OF PRESERNT ILLNESS
Client said that he had already spent time in this hospital 3 years ago for the same reason. 3
years ago, he felt sleeping problems and face delusions and hallucination, before this
.according to client he was absolutely right and was happy in his life
PAST PSYCHATRIST HISTORY:
As I have already explained 3 years ago client was admitted in the same hospital for the same
reason as he was facing sleeping problems and high energy in his arms and legs. This
indicates that he was diagnosed earlier by a psychiatrist.
FAMILY HISTORY:
According to the client, they are 6 siblings 4 brothers and 2 sisters. He belongs to a middle-
class family. His father had his own business and His elder brother also has his own business.
He said before coming to this hospital he was also a worker and was earning. His father was
also diagnosed with the same problems and was admitted in the same hospital for treatment.
PERSONAL HISTORY:
Client’s birth was normal. He lived a good and healthy life with his family and he had good
nature before diagnosis.
Milestone: client had normal growth and He speaks on time and his childhood growth was
normal and healthy.
Physical history: client had normal body parts, client had a healthy body and was looking
good.
Neurotic traits: client’s father had a same problem and was also admitted in the same
hospital. (NAYI ZINDGI)
Educational history: client studied till 3rd class. He had no interest in studies therefore can’t
continue his education.
Forensic history: He had no criminal background but he takes drugs. (mostly cigarette)
Marital history: He is married now.
Socioeconomic status: He belongs to a middle-class family. His brother and he himself

financially support after his father’s death.
PREMORBID PERSONALITY:
Client was completely normal by his physical appearance and had no handicap ness, he was
looking satisfied with his personality and had no feelings of shame or guilt about himself or
about his physical appearance.
PSYCHOLOGICAL ASSESSMENT:
(A) Informal assessment
(B) Formal assessment
A- INFORMAL ASSESSMENT:
Behavioral Observation
Clients behavior was good enough. His behavior was cooperative and he was wanting me to
ask more about him. On some questions he showed little bit hesitation but, on most questions,
he responds very quickly.
(II) MENTAL STATUS EXAMINATION:
(a)GENERAL APPEARANCE & BEHAVIOR:
(b)Speech:
Client’s speech was good. There was a hesitation in his speech. There was a little sequence in
his speech.
(c) MOOD:
(I)Subjective:
He was looking tired. He was disturbed with his problem.
(ii)Objective:
He was little bit conscious of his answers. He was looking emotionless.
(d) THINKING AND PERCEPTION:
(I) Thought Form:
There was flight of ideas. And his thoughts were not logical.
(ii)Thought Content:
He had some delusions and hallucinations of severe type.
(iii) Perception:
There were little bit illusions and hallucination present in client’s thoughts.
(e) SENSORUIM:
(I) Alertness:
Client was not so alert and attentive during my interview. He had full awareness about the
environment. He felt comfortable to talk in the presence of any person.
(ii) Orientation:
Client’s orientation about person, place and time was good.
(a)Person:
‫ت‬
‫ آپ کے ئسا ھکون ہ‬:‫سوال‬
‫ے‬
‫ می رے ب ھا ی‬:‫ج واب‬
(b) Place:
‫ اب آپ کہاں ہ ی ں؟‬:‫سوال‬
‫ می ں ہ سپ ت ال می ں ہ وں‬:‫ج واب‬
(c) Time:
‫ق‬
‫ ک ی ا و ت ہ وا ہ‬:‫سوال‬
‫ے؟‬
‫ دن‬:‫ج واب‬
ATTENTION AND CONCENTRATION:
There was a distractibility in his attention and concentration.
MEMORY:
Immediate:
His immediate memory was not good.
Recent:
His recent memory was little bit good.
Remote:
.His remote memory was not good
Calculation:
2+2=4
Fund of knowledge:
His fund of knowledge was not good.
Abstract Reasoning:
His abstract reasoning was little bit good.
(f) Insight:
He was not fully aware about himself.
(g) Judgment:
His judgement was much better and he was judging accurately.
(h) SUICIDALITY & HOMICIDALITY:

He had attempted suicide once in a life. He eated black stone but he was medicated on time.

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CASE # 1

Hospital NAYI ZINDGI

Education: Primary school

Marital status: Married

Siblings: 6 (4 brothers,2 sisters)

Birth order: 4th

His brother in law brought him to the hospital.

REASON FOR REFEREL:

According to the client,

He had no complaints for his family members.

He said he had some complaints about this hospital like,

Other patients are cruel and not cooperative.

Doctor don’t pay heed to me.

I feel loneliness here.

Marital history: He is married now.

Socioeconomic status: He belongs to a middle-class family. His brother and he himself

(A) Informal assessment

(B) Formal assessment

(II) MENTAL STATUS EXAMINATION:

(a)GENERAL APPEARANCE & BEHAVIOR:

He was looking tired. He was disturbed with his problem.

He was little bit conscious of his answers. He was looking emotionless.

(d) THINKING AND PERCEPTION:

(I) Thought Form:

He had some delusions and hallucinations of severe type.

Client’s orientation about person, place and time was good.

ATTENTION AND CONCENTRATION:

There was a distractibility in his attention and concentration.

His immediate memory was not good.

His recent memory was little bit good.

His fund of knowledge was not good.

His abstract reasoning was little bit good.

His judgement was much better and he was judging accurately.

(h) SUICIDALITY & HOMICIDALITY:

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