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Case Report No 2

Bio Data

Name: M. N.

Age 13 years

Sex Female

Religion Islam

Education 7th class (continued)

Occupation Student

Monthly Income Nil

Siblings 2 Sisters, & 2 Brothers

Birth Order 2nd child

Material Status Unmarried

Father living / dead Alive

Father’s education M. Com

Father’s Occupation Businessman

Father Income 70, 000

Mother living / dead Alive

Mother’s Education Matriculation

Mother’s occupation Housewife

Socio - economic – status Middle class

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Reason for Contracting Psychological Service

Client has some anxiety problem regarding exams. Her anxiety is the cause of poor

performance in exams but her performance in class tests is very good. Her parents are

confused that if she had academic problem or in understanding subjects than her class

tests should also be poor. But that low performance is only restricted to annual and

Mid-Semester exams.

Source of Referral

The client was referred by her mother because due to this exam anxiety client has

been de-permoted in 7th class.

Presenting Complaints

• She was worried about her exams.

• She became confused during exams.

• She is experiencing stress due to her de-permotion.

• Her mind becomes totally blank during exams.

Observational Assessment

Client was 13 years old, good looking girl and had a good hygiene. She was trying to

look calm but her gestures and postures were showing anxiety.

Personal History

There were no problems related to birth and early development is normal. His

relationship with her parents is good but she had a fear that her father could slap her.

Her mother told me that client’s father is a cool minded person and he never even

scolded children or taunted harshly. Client’s relationship with her siblings are good as

she take care of young siblings, help them in home work. She also had no specific

behavioral problems with her elder brother. She was a very good and obedient student

but from last year her performance was very poor in exams. Her parents changed the
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school because she refused to continue in the school, she was failed. In new school

her performance in daily tests are good, her teachers consider her a good student but

she failed in exams before summer vacations. So client has some serious problem

regarding exams which are interfering with her academic life.

Personal Medical History

She has been suffering from stomach problem for three weeks and also taking

medicine.

Family Medical History

Her mother has diabetes.

Family Psychiatric History

There is no psychological history in family.

Educational History

She was very good student through out the academic session. She always got good

marks. She was an obedient student. Her teachers like her. But from last year she has

been showing poor performance in exams and being failed in 7th class. She refused to

continue studies in the school she was failed and changed the school. But again in

exams before summer vacation she has been failed in all subjects.

Premorbid Personality

Client is living a normal life before one and a half year. But exam anxiety has

disturbed her academic life. She was a serious girl but enjoy with her siblings but

these days she was anxious about her poor performance in exams. She reported that

she was a good student and try to work more hard she knows everything but when

paper is being delivered she got blank.

Psychological Assessment

Psychological assessment has very important role in dealing with every type of client.
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Mental State Examination

• Appearance and Behavior

Her appearance was good. She dressed in neat and clean clothes, and no

hygiene problem.

• Posture and Movement

Her posture was normal but her movement was showing anxiety.

• Eye contact & Rapport

She kept good eye contact with the counselor. She developed good rapport

with the counselor because she was concerned that why her performance was

poor in just.

• Voice and Talk Rate

Her voice was normal but pitches and tone was showing inner confusion.

• Mood Subjectivity & Objectivity

Her mood was low in the beginning of first session.

• Illusion, Hallucination, Delusion

She has no illusions, hallucination and delusions.

• Cognitive Orientation

Her cognitive orientation of time, place and person was good. Her

memory was good. She was concerned about her problem that shows her

insight and wants to solve his problem by himself.

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Case Formation

Psychometric Administration

Psychometric administration is very important for counseling to explore client more

fully with valid and reliable psychological tests. Counselor had administered two tests

according to the situation of the patient that are as follows:

• Beck Depression Inventory (BDI)

• Beck Anxiety Inventory (BAI)

Beck Depression Inventory (BDI

The patient’s scores on the BDI, shows that she has minimal depression. Her

score on BDI are 8.

Beck Anxiety Inventory

The patient score on BAI is 7 that show minimal level of anxiety.