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
