Case record Proforma

Date:

Your Name:

Identifying Data:

Name - Mrs. A

Age – 75 years

Sex – Female

Education – Graduate

Occupation – Home maker

Marital Status – married

Socioeconomic Status – middle

Residence – Urban

Informant: self and husband

Reliability –

Adequacy –

Chief Complaints:

 Fear of dying
 Fear of being buried alive
 Fear of falling

She had been home bound around 10 years. She has fear that if she will go out something bad will
happen to her. She do not allow her husband to go out of the house. She mostly stays in her room.
She has fear of dying and thinks that she will not be found in time, if something bad happens to her.
She thinks that she will go to hell.

Onset: acute

Course: continuous

Precipitating Factors/Stressors: Death of her sister in 2009

History Of Present Illness: The Patient was completely well around 10 years ago. She stopped moving
out of her room after her sister’s death and clinged more to her bed when she was diagnosed with
cancer in the same year. When her sister died in 2009, she went to the hospital but did not entered
her room. After this event, she started showing panic symptoms such as shortness of breath, sweaty
palms, dry mouth, palpitations, tremors and sudden fear of dying.

Associated Disturbances: Sleeplessness, Restlesness

Negative History:
Past History: na

Past Psychiatric history –na

Medical and Surgical history – She had cancer in 2009 which was removed surgically.

Family History: Mrs. A is 75 years old who resides in Uttar Pradesh with her husband. Her children
stay abroad. She spent her childhood in Uttar Pradesh. Her sister died in 2010. She was married and
elder to her. Her husband is very helpful and caring. He has a general store in Uttar Pradesh.

Personal History: Mrs. A is a homemaker. She got married at the age of 26 years. She stopped going
out of her room after her sister’s death. She was very close to her elder sister and spent most of her
time with her when her husband went for work.

Occupational History – homemaker

Menstrual History –

Sexual History –

Marital and Relationship History – She got married at the age of 26 years.

Premorbid Personality –

 Social relations: She is an introvert person and likes to spend time with her close ones which
includes her husband, children and sister.

 Mood: She becomes restless whenever asked to go out of the room. She becomes angry and asks
everyone to leave the room.

 Character:

 Interpersonal relationships: She had good relationship with family.

 Energy and Initiative: Low at energy. She does not get involved in household chores.

 Habits: She likes to read books.

Mental Status Examination

General Appearance and behaviour: The patient is an elderly white female who appears to be
physically healthy and appears younger than her age. She was cooperative but seemed to be in
distress, and sometimes even tearful. She also had a hearing problem, which was causing some
difficulty in communicating with her. She denied any suicidal thoughts. Her insight and judgement
was good, apart from her fear of being alone and excessive worries.

 Alertness : Thoughts were goal directed. She was alert and oriented to time, place and person.

 Appearance: She was dressed neatly . Her mood was anxious, but not depressed.

 Nutritional status: Healthy

 Dress and grooming: Well dressed

 Eye contact: Maintained eye contact throughout the session

 Posture: She had a slouchy back.

 Gait:

 Rapport:

 Attitude towards examiner: She became comfortable after the fourth session where she talked
more as compared to the last sessions.

Speech: Her speech was of regular rate and volume., but somewhat circumstantial and ruminative
on the fear of leaving her room and being alone.

Emotions:

 Mood: Her mood was anxious, but not depressed.

 Affect (range, reactivity, intensity, mobility, appropriateness): “mujhe khudke kamre mei hi rehna
hai”, “mujhe pareshan karte hai bacche, bahar jane ko bolte hai”, “mujhe nahi jana kahi bhi”

Thought: Thoughts were goal directed. She was alert and oriented to time, place and person.

 Form : Normal thought formation

 Stream:

 Content: She denied any symptoms consistent with obsessions and compulsions other than
obsessive thoughts of fear of death.

Perception: No abnormality detected.

Consciousness: well aware about surroundings

Orientation: The patient was oriented to time, place and person.

Attention and concentration: she was attentive.

Calculations:

Memory (Immediate, recent, remote): Concentration and memory were intact.

Intelligence: Average

Insight: Her insight and judgement was good, apart from her fear of being alone and excessive
worries.

Judgment:

 Test – intact

 Social – impaired

 Personal – impaired

Proposed Diagnosis: Diagnosed with panic disorder without agoraphobia

Biopsychosocial model (Risk, precipitating, maintaining and protective

factors):
Management Plan:

She was given behavioral therapy and exposure therapy and her home attendant was educated to
carry out the proposed plan. Patient was encouraged in the beginning to leave her room for few
minutes to few hours. After a few weeks she was able to walk up to the living room. Slowly and
gradually she was encouraged to go to a different room each day in the apartment. At one point she
was escorted up to the front door of the apartment. Finally she managed to build enough courage
and will power to step out of her apartment into the hallway. It took months before she was able to
come down the lobby. Sertaline was subsequently titrated up until a dose of 150 mg pod qd. For few
weeks she would only come to the stairs accompanied with her caregiver. She was continuously
encouraged to gradually come out of her home. In may of 2019 after the home visit, she came to the
parking lot to see us off.

Continuous and gradual psychotherapy eventually improved her condition.

 Referrals

 Psychosocial treatment