Case history

General demographic Information

Name: Kailashben Kanabhai Rawal

Age: 35

Religion: Hindu

Marital status: Single

Education: B.A., B.Ed

Occupation: Teacher

Presenting chief complaints:

 Patient said that she has fever and headache and complained about pain in her
right hand. Patient said that this was the reason for her admission in the mental
hospital.

 Delusion of Persecution:
 Patient believes that her sister and nephew are plotting against her.
 Someone is harassing her every night and not letting her sleep. When asked
“who is harassing her?”, she was unable to answer.
 “Someone has ruined my eye sight.”
 “My family is blackmailing me”
 “Someone follows me at night”
 “Some girls have ruined my eyesight after she took my interview.”

 The patient insisted that all the intern girls were her previous students, and she
used to teach them in school. She first addressed inters with a different name
and then she proceeded to tell the interviewer how she used to teach them.

 Depressed mood

 Difficulty concentrating

 Sleep disturbance

 Withdrawal from family and friends

 Disturbance in appetite

 Jealousy
  Relationship stressor: Breakup with boyfriend (as told by family members)

Family history:
Nuclear family

One sister died when Kailashben was in 7th.

Supportive attitude of family members towards the patient ‘s illness

Educational history:
B.A., B.Ed

Occupation history
School teacher

Personality traits:
Extrovert and talkative

Premorbid personality
Interpersonal relation: Extrovert, social and outgoing.

Premorbid mood: Optimistic, stable

Attitude to self and other: Self confident, thoughtful of others

Attitude to work and responsibility: Independent and self reliant.

 Mental Status Examination
General appearance and behaviour

General appearance:
Looks comfortable talking to interviewer
Adequate dressing

Attitude toward examiner:

Cooperative
Attentive
Appears interested
Aggressive

Comprehension:

Partially impaired

Gait and posture

Normal

Motor activity:

Normal

Social manner and non verbal behaviour

Increased
Normal eye contact

Speech

Rate and quality of speech

Spontaneous and rapid

Volume and tone of speech

Normal

Flow and rhythm of speech:

Smooth

Mood and Affect

Depressed mood
Thought

Stream and form of thought

Poverty in the content of speech

Patient kept saying “happy new year” many times.
She kept mentioning a friend named Samir many times during the conversation
without any context, when asked who he was, she told the interviewer to forget him.
Illogical thinking
She insisted to one of the interviewer that agriculture means “our character” or “what
we are”, and became aggressive when the interviewer tried to tell her the word’s true
meaning.

Content of thought

She strongly believes that all the interns including the interviewer are her previous
students.
Delusion of persecutions- thought insertion and thought withdrawn
Suspiciousness

Hallucination

--

Cognition

Consciousness

Alert and conscious

Orientation

Oriented of time and place

Not oriented to the person: (e.g., she kept referring the interviewer her student)

Attention

Normal, attentive

Memory

Immediate recall – normal

Recent memory – normal
Remote memory – Partially impaired

Intelligence
Partially intact – patient had difficulty saying the names of the month backwards.

Abstract thinking

Proverb testing – Normal, patient was able to tell the meaning of the proverb.

Insight

Attitude towards her present illness - slight awareness of being sick and needing help,
but denying it at the same time. Attributing it mostly to external factors.

Judgement

Normal