SAMPLE CLINICAL ASSESSMENT REPORT

IDENTIFICATION DATA NAME AGE SEX RACE EDUCATION OCCUPATION MARITAL STATUS PROBLEM CHIEF COMPLAINT Lucy experiences auditory and visual hallucination after her husband died in a car accident. She closed herself in her house. She was losing motivation to do anything. Besides, she lost her appetites and lots of her weight. She also felt exhausted most of the time and slept a lot daily. REASON FOR REFERRAL The patient was referred for psychotherapy to control her psychotic major depression symptoms. HISTORY OF PRESENTING ILLNESS The patient was grieved when her husband met a car accident and pass away in January 2010. Before that, she was having a wonderful life and family. After the accident, she began grieving and depressed. When she was 16, her father died of heart attack. She was sorrow but she managed to overcome her grief. : Lucy Chong Ai Hwa : 58 : Female : Chinese : Graduated at local university : Retired, School teacher : Widowed with three children and a grandchild

DATE OF BIRTH : 22 June 1952.

2 After the death of her husband, she was unable to manage her grief. She started to blame herself and felt extremely guilty. She blamed herself for not persuading hard enough to retired. She thought that if she had been more persistent, her husband would not meet the accident and died. After the trauma, she began ignoring and stopped talking to her neighbours. She began locked herself inside her house. She used to be a religious person but she stopped going to church after her husband was died. Before this, she spent a lot of time on gardening. After the accident, she lost her interest on it and felt no mood or motivation to do anything. She felt that everything became meaningless. She slept a lot. She tried to sleep as much as she can to forget her grief. Although she slept most of the days, she still felt tired and exhausted all the time. Besides, she began losing her appetite and loss lots of weight. She said that she only eat whenever she felt hungry and that was not very frequent. Sometimes, she can go without foods for the whole day. After 7 months from her husbands death, she began to able to see and hear her husband. She realized that is auditory and visual hallucination, just she would feel better if she believed it is true. She said that she can only see her husband when she was down, sad or lonely. The last time she saw her husband was 2 months ago. Sometimes, she felt there is nothing worth to live anymore. The suicidal thought was flash on her mind occasionally but she just brushes those thoughts away. Her children and her grandchild were the reason to keep her go through this.

PAST PSYCHIATRIC AND MEDICAL HISTORY Lucy met with a psychiatrist, Dr. Herman, and got a medical prescription, Zoloft two months ago.

SOCIODEMOGRAPHIC DATA FAMILY HISTORY

Father Died of heart attack when Lucy was 16 y.o. Mother Died when Lucy was 40 y.o.

Died when Lucy was 56 y.o.

Patient 58 y.o.

Died in a car accident when Lucy was 57 y.o.

32 y.o. IT Engineer

25 y.o. Student

30 y.o.

5 y.o.

Father Lucys father was a shopkeeper of a laundry shop. She described her father as a very typical Chinese father. He would not show much affection to his children but he provided to his family with faithful. She also described her father was a nice but distance person. There had not much conversation between both of them except the matters concerning the shop. She never discussed about her personal issues with him, even her personal problem, she would never thought to go to him. Her father was died of heart attack when she was 16 years old. Mother The patients mother was totally different with her father. She was generally more affectionate towards her children. She was a housewife but would sometimes bake cookies for sale especially during festive seasons. However, Lucy claimed that

4 her mother loved more with her sons than her daughter. She said that she and her sister were always being blamed when her three younger brothers misbehaved. She said her mother love them but expected them to be more responsible. Her mother also taught her that women must look after the men. Her mother was passed away when she was 40 years old. Siblings The patient is the second child in a family of five children. He has one older sister and three younger brothers. She said that she was close to her sister since their age difference was only two year. She described their relationship were like best friends. Her sister was who she turned to when she needed a shoulder to cry on. Her sister was always there with her when she when she needed helps. Her sister was died of breast cancer two years ago. She was in a way that her sister passed away the way she did. It was torturing her when she saw her sister struggled with the cancer. She was almost relived when her sister died because she thought that her sister did not have to suffer anymore. She said that she was not very close to her three younger brothers. She didnt like her brothers because they always got her into troubles. Besides, her mother always defended her brothers no matter what. She said that she was not hate her brothers but just dislike them. Since them become older now, they begin to forget all those feeling and treasure their family bond more.

PERSONAL HISTORY Early development There were no irregularities in her childhood development. She used to help her father look after the laundry shop in Klang. Although her father seems less affectionate, she felt closer to him than her mother. She would always find ways to seek his approval. That is the reason she was always extra helpful in the shop. She described herself have always been socially reserved. She always feels awkward and self-conscious in the presence of larger groups of children.

School The patient described herself as a shy student in school. She also said that she was not very attractive because she was rather fat and clumsy. She always studied harder and always tried to make her father proud of her. When she was in her secondary school, she met her husband, Richard. She had only one or two close friends in school. After her secondary school, she studied education locally. She did not really go dating with any boys. She simply studied and try to do her best in the university.

Occupation When the patient was graduated, she was posted to a secondary school in Johor Bahru. She worked as a teacher and she was retired.

Marriage Lucy was married in 1982. She was 30 at that time while her husband was 34. It was a love marriage. Their first met was in her secondary school. They were studied at a same school. She only knew him by name then. They were separated after secondary school. She studied education locally and he did civil engineering overseas. After she was graduated and posted to a secondary school in Johor Bahru, she attended a local church there. She met him again at the church. He was working on a construction project in Singapore. They started going out for lunch after church and eventually ended up getting married. CHILDREN She has 3 children: a 32 year-old son, Brandon, a 32 year-old daughter, Sarah, and a 25 year-old son, Lucas. Her daughter, Sarah was married and has a 5 year-old daughter, Rebecca. SUBSTANCE USE

6 The patient neither smokes nor drinks.

PREMORBID PERSONALITY She described herself as not an outgoing person. She talked to her neighbours occasionally. She was a religious person. PRESENT CIRCUMSTANCES The patient is able to function normally on most of the time after she took the prescription. Her mood was improving within the first 2 weeks. Sometimes, she would have some side-effects like feel nauseous, dizzy and not able to sleep.

MENTAL STATE EXAMINATION GENERAL APPEARANCE The patient came in for the session dressed neatly and plainly in white blouse and brown lady pants with no accessories apart from her golden earrings. She wore spectacles and has straight shoulder length hair. She seemed rather thin and frail. She also looked a little pale and uncomfortable. A whiff of light perfume permeated the room as she walked in. Initially, she seems quite relaxed in the session. Depressed mood was observed during the sessions. SPEECH She spoke fluently in English. She spoke smoothly at normal pace. Her speech was coherent and relevant. MOOD AND AFFECT She was generally in a good mood at the beginning of the session. She seemed depressed at times when she talked about her sister and husbands deaths. Nevertheless, she would still manage to maintain a smile. THOUGHT AND PERCEPTION

7 Observation throughout the sessions did not suggest any thought or perceptual disturbances. COGNITIVE FUNCTIONS Orientation The patient was orientated to time, date, day, month, year, place and person, as evidenced by her ability to keep her appointment with the therapist. Memory She was able to remember both past and recent events in her life. Attention and concentration She is attentive and able to maintain concentration throughout the sessions. General knowledge and intelligence Based on her highest level of education and content of conversation, she is estimated to have a higher than average intelligence. She reads a lot of grieving books and was quite knowledgeable on managing grief techniques. Abstract thinking The patient was able to grasp psychological concepts as was explained by the clinician during the sessions. Judgement She has good judgement of her problem. She knew that she needed to seek help for her depression and hallucination. She refused to seek help because she might feel better if she believed the hallucination is true Insight She has good insight of her problem. She realises her husband was a hallucination, although she tried to believed it is true.

CHRONOLOGY OF EVENTS LEADING TO PRESENTING PROBLEM YEAR 1968 1992 2008 January 2010 January 2011 EVENT Father died of heart attack when she was 16. Mother passed away when she was 40. Sister died of breast cancer. Husband died in a car accident. Sought psychiatric treatment for depression and hallucination.

CLINICAL DIAGNOSIS Axis I Axis II Axis III Axis IV Axis V : 296.24 Psychotic major depression disorder, single episode. : Dependant personality trait. : None. : Husband died in a car accident a year ago. : 0.