Name: J Y
Education: 5th Standard
Socioeconomic status: Lower
Location of residence: Rural
Marital status: Unmarried
Informants: Hospital records, Patient self
Information: Reliable, Inadequate
PRESENTING COMPLAINTS AND THEIR DURATION
Shows childish behavior and wandering behavior. No development in behavior and thinking along with age. It was identified from 5th standard onwards.
HISTORY OF PRESENT ILLNESS
Mode of onset: Insidious
Precipitating factor: Smoking
Duration: Since 5th standard joy does not show improvements in his cognition. His intellect seems to be below average. He often engaged in childish behavior and shows wandering tendency.
No reports of physiological problem are available.
Treated at Government hospital.
Family history of mental illness: No history of having any mental illness
Birth and Early Development: Normal birth.
No complications in the mother were reported.
Developmental milestones: Delayed
Behavior During childhood:
Sleep disturbances: No Thumb sucking: No Nail biting: No Bed wetting: No
Stammering: Yes Tics: No Severe temper tantrums: No
Conduct disturbances: Not reported.
Relationship with parents: Good.
Relationship with siblings: Good.
Relationship with peers: Good.
Physical illness during childhood: Not available
Age at which schooling began:5 years Educated up to: 5th Standard
Scholastic Performance: Below average
Learning problems: Not available
Relationship with teachers: good
Relationship with peers: good
No history of occupation. Patient reported that he had owned a tailoring shop.
Menstrual History: NA
Sexual history is not available.
Marital history: NA
History of Substance abuse
Reports of smoking are present. But the detailed is report is not available.
Extravert, submissive, friendly, helpful to others, believe in religion, good self concept, trust others, conforming to rules.
Pattern of Eating, Sleeping and excretory functions: Regular
MENTAL STATUS EXAMINATION
General Appearance and Behavior
Personal hygiene: Disheveled Dressing: Appropriate
Eye to eye contact: Established and maintained
Rapport: Adequate Reality contact: Present
Any tics or mannerisms: Holding his hands continuously on the face.
Reaction time: Decreased Tone: Normal
Tempo: Slow Volume: Decreased
Stream: Thought block
Objectively: Happy Subjectively: Happy
Range: Normal Reactivity: Present
Lability: Absent Congruent to thought
Appropriate to situation
a) Time: Intact
b) Place : Intact
c) Person: Intact
Attention and concentration:
a) Immediate: Intact
b) Recent: Intact
c) Remote: Intact
He made some additions to the information.
a) General information: Inadequate
b) Comprehension : Inadequate
c) Arithmetic : Inadequate
d) Abstractibility –
Based on clinical assessment intelligence seems to be: Developmentally Delayed
a) Personal: Intact
b) Social : Intact
c) Test : Intact
Pharmacotherapy, Insight and Absent.
Mr. Jy is 37 year old unmarried male educated up to 5th standard, with no history as an employee comes from a lower socio economic rural background, who was premorbidly an extravert, submissive, friendly, and helpful to others, believed in religion, had good self-concept, and trust others, conforming to rules, has regular pattern of eating, sleeping and excretory functions, cooperating, holds his hands continuously on the face , always ready to sing in front of others, with little care on personal hygiene, but conscious about physical health, has established and maintain eye contact, with normal psychomotor activity, decreased reaction time, normal tone, slow tempo, decreased volume, sometimes experiencing thought block, and auditory hallucinations, with happy mood which appropriate to the situation, but inadequate in general information, arithmetic, comprehension, abstractablity, has intact memory, intact judgment, with no insight, and is managed through pharmacotherapy and vocational training.
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