NIMHANS DIGITAL ACADEMY

Case record Proforma

Date:1/06/2019 Your Name:Bhargava Ram Yasarla

Identifying Data:
Name - DS
Age –11 years
Sex –Male
Education –5th Class
Occupation –Student
Marital Status – Not married
Socioeconomic Status – Middel
Residence – Urban

Informant: Mother and Father

Reliability –100%
Adequacy –80%

Chief Complaints:
1. Poor academic performance
2. Poor memory

Onset: acute

Course: continuous

Precipitating Factors/Stressors:

History Of Present Illness:

Associated Disturbances:

Negative History:

Past History:

Past Psychiatric history –

Medical and Surgical history –

Family History:
Family history reveals that it is a non consanguineous marriage. It is
a nuclear intact family having 4 members. Parents have low
educational qualification. The family has middle socio-economic-
status. They reside in urban locality in a government quarter. No
family history of mental illness, mental retardation, hearing
impairment, vision impairment or fits is reported.

Personal History:

Birth History –renatal history reveals that the conception age of the
mother was 30yrs and she had regular antenatal checkups. Natal
history reveals it was a full term normal delivery, birth cry was
immediate, birth wt. was normal, birth colour was normal, no other
significant information was reported. Postnatal history says that
breast feeding immediately after birth, client had fever at the age of
1yr, immunized as per schedule.

Behaviour during childhood – Narnal

School History – The client joined the regular school at the age of
4yrs, continuing in the same school in 5th class.

Occupational History –The client can initiate his own play activities,
enjoys group play and plays cooperatively with the age group peers.
The client helps his mother in household chores, makes minor
purchases.

Menstrual History –nill

Sexual History –Nill

Marital and Relationship History –Nill

Premorbid Personality –
 Social relations:poor
 Intellectual activities:poor
 Mood:normal
 Character:-
 Interpersonal relationships:low
 Energy and Initiative:nurmal
 Habits:-

Mental Status Examination

Behavioural Observation- The client is a 11yr old, right handed boy.
His physical built is appropriate for his age. He maintains proper eye
contact, communicates verbally and is fairly co-operative during the
assessment. His attention could be aroused and sustained till task
completion, with proper eye hand coordination. He is oriented towards
person, place and time, follows 2 to 3 step instructions. He
understands monetary transactions and makes minor purchases. The
client demonstrates emotions through proper facial expressions and
understands mood in others. He follows a proper sleep pattern. The
client is the first issue from a non consanguineous marriage. He has
one younger sister. He plays cooperatively with his sister as reported
by his parents.
General Appearance and behaviour:
 Alertness -low
 Appearance- appropriate
 Nutritional status-low
 Dress and grooming- age appropriate
 Eye contact-establish and low level sustained
 Posture
 Motor activity- age ppropriate
 Gait-
 Rapport-established
 Attitude towards examiner- passive

Speech:
 Tone
 Tempo
 Volume
 Coherence
 Relevance

Emotions:
 Mood
 Affect (range, reactivity, intensity, mobility, appropriateness)

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:

Consciousness:

Orientation:

Attention and concentration:

Calculations:
Memory (Immediate, recent, remote):
DEVELOPMENTAL HISTORY

Developmenatl milestones Age at which attained

Neck holding 6months

Sitting 10months

Walking 14months

First word 12months

Two word phrase 30months

Sentences 3yrs

Toilet control < 3yrs

Intelligence:On MISIC the client’s Verbal Quotient (VQ) is 97.4,

Performance Quotient

(PQ) is 99.4 and the total Intelligent Quotient (IQ) is 98.4.

Insight:

Judgment:
 Test –
 Social –
 Personal –

Proposed Diagnosis:

Biopsychosocial model (Risk, precipitating, maintaining and

protective factors):
Based on information given by parents, developmental history, school
history, behavioral observation and the results of psychological tests
administered, the client is currently functioning with “Average
Intelligence”.

SUMMARY

DS, a 11yr old boy was brought by his parents with the chief
complaints of poor academic performance and poor memory. The
client was assessed on DST, VSMS and MISIC respectively. The scores
on the above tests reveal that the client is functioning age
appropriately.
Management Plan:
 Parental counseling and guidance

 Training for attention and concentration

 Remedial teaching

 Supportive Environment

Referrals
 Govt Clinical Psychologist For SLD assessment