HISTORY COLLECTION ON ADJUSTMENT DISORDER
A. IDENTIFICATION DATA:
Name : Mr. Sankar
Age : 21 Years
Sex : Male
Father’s name : Mr. Rajendran
Education : B.Tech
Occupation : Nil
Marital status : Single
Religion : Hindu
Diagnosis : Adjustment Disorder
Address : Cheranmahadevi
Informant name : Mrs. Sarasam
Relationship with the patient : Mother
Length of acquaintance : 21 Years
Reliability of information : Reliable and Adequate
B. CHIEF COMPLAINTS:
i) According to Patient:
Patient said, “ I am afraid of my future. I feel worthless. I don’t want to live”.
ii) According to Informant:
informant said that his son has
C. HISTORY OF PRESENT ILLNESS:
Duration of illness is 3months. Mode of onset is acute. predisposing factor is ADHD in
childhood. Precipitating factor is stress due to project work and final exam. Aggravating factor is fear.
He has the complaints of suicidal ideas and attempt (hanging) 1 month ago, palpitation, fearfulness,
sleep disturbances, reduced food intake, anhedonia, lack of concentration since 3 months. After
investigation like history collection, mental status examination, lab investigation, psychiatrist diagnosed
him to have Adjustment disorder. Now, he is under treatment such as Inj.BE Plex 1amp 1ml od,
Tab.Depcital -C bd, Tab.Veniz XR 150mg bd, Tab.Protopan 40mg bd, Tab.Orzine 50mg hs, Tab.Nithra
10mg hs.
D. PAST PSYCHIATRIC HISTORY:
There is no significant past psychiatric history.
E. PAST MEDICAL AND SURGICAL HISTORY:
He had acute appendicitis and undergone lap. Appendicectomy 1 year ago in shifa hospital,
Tirunelveli.
F. SOCIO ECONOMIC BACKGROUND:
His mother tongue is tamil. He can speak and write English, tamil. His father Mr. Rajendran is
the bread winner of the family. His house has all the facilities like water, electricity, drainage system.
G. FAMILY HISTORY:
i) FAMILY TREE
ii) FAMILY COMPOSITION
S.No Name of the Age Gender Relationshi Education Occupation Monthl Health
family p with the y status
member client Income
th
1. Mr.Rajendra 45 M Father 12 Driver Rs. Healthy
n 20,000
th
2. Mrs. Sarasam 40 Fe Mother 10 Homemaker Nil Healthy
3. Mr. Sankar 21 M Self B.Tech Nil Nil Adjustment
disorder
4. Ms. Kavitha 17 Fe Sister 11th Nil Nil Healthy
iii) DETAILS OF FAMILY FUNCTIONING:
He belongs to middle socio economic background. Type of family is nuclear family. His father
mr. Rajendran plays a leadership role in the family. There is good communication among the family
members.
H. HISTORY OF ILLNESS IN FAMILY:
Psychiatric :
There is no significant family history of psychiatric illness such as similar illness, other illness,
other major behavioral problems like delinquency, personality problems, suicide, substance use,
epilepsy, mental retardation.
Medical :
There is no significant family history of hereditary diseases like diabetes mellitus, hypertension,
cardiac diseases.
I. TREATMENT HISTORY:
Inj.BE Plex 1amp 1ml od,
Tab.Depcital -C bd,
Tab.Veniz XR 150mg bd,
Tab.Protopan 40mg bd,
Tab.Orzine 50mg hs,
Tab.Nithra 10mg hs.
J. PERSONAL HISTORY:
i) Perinatal history:
Antenatal period of his mother was uneventful. He got delivered as a full term male baby by
spontaneous normal vaginal delivery. He cried immediately after birth. He had no birth complications.
ii) Childhood history:
He had good physical health during childhood except common cold, fever. He was immunized
properly as per national immunization schedule. He had behavioral problems such as enuresis, nail
biting, ADHD, demanding behavior. Home atmosphere during childhood was satisfactory.
iii) Adolescent history:
He has no behavioral problems during adolescence such as delinquency, smoking, drug use,
smoking, over weight. There is no parental lack and no habitual absent from home during his
adolescence.
iv) Educational history:
He started his education at the age of 6 years. He is studying final year B.Tech in SCAD
Engineering college, Cheranmahadevi. He experienced difficulties in completing his project. He is
afraid of failing exam. He is a average student in studies. He has good relationship with teachers,
classmates.
v) Play history:
He is interested in playing indoor games such as chess, carrom board
vi) Occupational history:
He is not working.
vii) Marital and Sexual history :
He is unmarried. He has secondary sexual development in his body such as hoarse voice, broad
shoulder, facial hair.
K. PRE-MORBID PERSONALITY:
i) Social relations:
He is an introvert. He has good relationship with friends, family.
ii) Intellectual activities :
He is interested in playing indoor games such as chess, carrom board.
iii) Mood:
He is a pessimistic person.
iv) Character:
He has good attitude towards work and responsibility. But he fears a lot in doing tasks.
v) Fantasy life:
He dreams of failing in exams.
vi) Habit:
He likes to eat non-vegetarian foods. He has poor sleeping pattern due to fear of studies and
exam. He has normal bowel and bladder elimination pattern.
