NIMHANS DIGITAL ACADEMY

Case record Proforma

Date: 18-March 2019 Your Name: Bhargava ram Yasarla

Identifying Data:
Name – Miss:G
Age –13.8yrs
Sex –Female
Education –5th Class
Occupation – Student
Marital Status – Unmarried
Socioeconomic Status –Middle Class
Residence – Urban/rural- - VijayawadaUrban

Informant: Mother , Father and elder Brother

Reliability –fair and 90%

Adequacy –Yes

Chief Complaints:
 Not getting marks in exam
 Not able to read and write properly
 Low memory
 Low concentration

Onset:abrupt/acute/insidious

Course: continuous

Precipitating Factors/Stressors:

History Of Present Illness:

Associated Disturbances:

Negative History:

Past History:

Past Psychiatric history – at age of 3 years she diagnosed with epilepsy from that
till 7 year use medication , latter stopped with doctor suggestion

Medical and Surgical history – No

Family History: she is it younger girl child to her parents living with her parents
and brother , she has one elder brother , father works as electrician and mother
is a home maker , brother 13 years studying 8 class . Father’s age 33yrs,
Education qualification 10th class, Mother’s Age 29 yrs doesn’t gone to school. No
family history of Mental ill or any disability, fathers father had die at age of 52
years , 5years back due to liver problems (drinking more alcohol) , but her father
don’t have habit of alcohol regularly, but drinks 4 or 5 times in a year( Father
reported ). She is very closes to her father. Every one in family has good and
strong emotional bonding to each other.

Personal History:

Birth History – birth cry delayed , parents report that she is everything normal
till 3years , in fever she got seizures , after that onwards the speech vocabulary
not according to the age .

Behaviour during childhood – she is sociable person and parents says no issues
of behavior problems

School History – she went Pre-school at age of 3, at age 5 to Govt., school , still
she is in that same school 5th class .

Her speech vocabulary not up to the age and her finger grip is not proper

Occupational History – she plays her-self , not going out of the home and she
loves plays with children younger than her age . She help mother in household
work , cleaning home and cutting vegetables and other petty things.

Menstrual History – No yet

Sexual History – No

Marital and Relationship History – No

Premorbid Personality –
 Social relations: she speaks good with guest , grant parents and who come
to her home , no friends in class ,
 Intellectual activities:
 Mood: active and pleasant
 Character:
 Interpersonal relationships: only with family members
 Energy and Initiative: normal and adequate
 Habits: playing with cooking toys

Mental Status Examination

General Appearance and behaviour:

  Alertness = average, instructions need to tell two are more times
 Appearance= age appropriate
 Nutritional status = Good
 Dress and grooming = age appropriate
 Eye contact = established and sustained
 Posture = Normal
 Motor activity = below to her age level
 Gait : Normal , walks slowly
 Rapport = established and sustained
 Attitude towards examiner =positive

Speech:
 Tone = soft
 Tempo= normal
 Volume= Low
 Coherence= normal
 Relevance= normal

Emotions:
 Mood = always in soft and happy
 Affect (range, reactivity, intensity, mobility, appropriateness): appropria

Thought:
 Form (circumstantiality/tangentiality/ loose associations/Word salad)
 Stream (Flight of ideas/ retardation of thinking/ perseveration/ thought
blocking)
 Possession (Obsessions and compulsions/ thought
alienation/insertion/deprivation/ broadcasting)
 Content

Perception:

She exhibits that her skills not like other in her age

Consciousness:

She know her abilities

Orientation:
She have place and time orientation and why she came to this place

Attention and concentration:

Her attention is adequate and concentration is good

Calculations:
She can read and write 100 numbers , single digit additions only
Memory (Immediate, recent, remote):
She did has good memory on live events and movies
She did number repeat till 4 digits and back word 3 digits

Intelligence: below average

Insight: yes

Judgment:
 Test –
 Social –
 Personal –

Proposed Diagnosis: Intellectual disability

Biopsychosocial model(Risk, precipitating, maintaining and protective factors):

BIOLOGICAL PSYCHOLOGICAL SOCIAL

Risk birth cry delayed low self-esteem deprived
environment ,
parent education
precipitating seizures
maintaining plays with
children younger
protective factors Family support

Age, physical
development

Management Plan:
 Referrals
Special Education
Occupational Therapy
Language Therapy

Psychosocial treatment
Social skills training

DEVELOPMENTAL PSYCHOPATHOLOGY CHECK LIST FOR CHILDREN

Sl No Summary Total Score Cut Off Obtained
Score
1 Dev. History 10 3 4
2 Dev. Problems / Disorders 10 5 2
3 HyperKinesis 4 2 0
4 Conduct Disorder 8 4 0
5 Learning Disorder 6 3 5
6 Emotional Disorder 9 3 2
7 Obsessive Compulsive Disorder 1 1 0
8 Somatisation 9 3 1
9 Psychoses 12 3 0
10 Family History 7 - 0
11 Stressors 16 - 2
12 Temperament 17 - 1