H i s t o r y B i o g r a p h i c a l d a t a : Patient's n a m e : s e p g h u l a m n a b i A g e : 4 9 y r s G e n d e r : m a l e O c c u p a t i o n : c o o k i n a r m y m e s s M a r t i a l s t a t u s : m a r r i e d , f a t h e r o f 5 c h i l d r e n
P r e s e n t i n g w i t h t h e c o m p l a i n t o f : A l t e r e d m o o d D i s t u r t e d s l e e p I r r e levant t a l k S e l f n e g l e c t Aimless w a n d e r i ng F r o m 1 y e a r , aggravated i n p a s t 1 4 days
H i s t o r y o f present i l l n e s s : M y p a t i e n t i s u n d e r psychiatric c a r e s i n c e 2 1 7 / 2 1 8 a n d o n a n t i p y c h o t i c s p r e s c r i b ed f r o m c i v i l s e t u p h o s p i t al s w a a b i . Accor ding t o secondary data , f r o m h i s b r o t h er i n l a w he d e v e loped t h e s e s y m ptoms a f t e r h i s mother's d e a t h .
P a s t medical h i s t o ry : N o h i s t o r y o f any f e v e r , fits , epilepsy . N o h i s t o r y of IHD a n d D S H . N o h i s t o r y o f any o t h e r m e d i c al i l l n e s s i n p a s t . N o h i s t o ry o f a n y d r u g o r substance abuse .
P a s t surgical h i s t o ry History o f ankle fracture i n c h i l d hood . N o o t h e r history o f any s u r g e r i c a l p r o c e d u r e o r hospital stay for a n y i l l n e s s .
F a m i l y history N o f a m i l y history of psychiatric i l l n e s s e s i n f i r s t d e g r e e r e l a t i v e s . H e h a s 6 s b l i n g s and h e i s 4 t h a m o n g s b l i n g s h i p . Father i s 6 5 y e a r s o l d a l i v e and mother i s d e a d 5 y e a r s a g o .
P r e m o r b i d personality : B e f o r e i l l n e s s m y patient w a s d e s c r i b e d b y f o l l o wing a t t r i but es C a l m b u t s h o r t t e m p e r e d Dedicated t o w a r d h i s Jo b a n d w o r k a s s i g n e d t o him L i k e t o e n j o y h i s o w n company rather then being , s o c i a l . Over think e r .
P e r s o n a l h i s t o ry : B o r n w i t h SVD a t h o m e , n o h i s t o ry o f prenatal a n d a n t e n a t a l complications , h e a c h i e v e d his m i l e s t o n es at a v e r a ge a g e . s t a r t e d g o i n g to s c h o ol a t a g e o f 5 y e a r s , w a s a v e r a g e i n studie s A c h i e v e d p u b e r ty a t t h e age o f 1 7 years , a n d already k n e w a b o u t it f r o m the counseling b y his c o u s i n . Hetrosexual o r i e n tation Marrie d a t the a g e o f 2 8 years w i t h h i s c o u s i n s i s t e r , satisfied m a r r i e d l i f e Have 5 c h i l d r e n f r o m h i s w i f e and wants h i s e l d e r m o s t d u g h t e r t o become a n a l m m a and teach Quran .
MSE ( mental s t a te e x a m i n ation ) Appearance a n d behaviour : a 4 9 y r s o l d , m a l e o f a n a v e r a ge h e i g h t a n d b u i l t , , n o t m a i n t a i n ing e y e c o n t a ct , s i t t i n g straight o n the c h a i r . S p e e c h : irrelevant M o o d a n d e f f e c t : i r r i t a t b l e m o o d w i t h s u s p i c i ous effects o n f a c e . S e n s o r i u m / o r i e n tation : w e l l o r i e n t e d P e r c e p tion : a l t e r e d perception Thoughts : d e l u s i o n al thoughts followed b y hallucinations .
MSE ( cont . ) C o g n i t i o n : i n t a c t M e m o r y : i n t a c t Insight : i m p a i r e d J u d g e m ent : i m p a i r e d j u d g e m e nt .