Training-only case history. For educational and supervision purposes.
Created: 03 Jun 2026, 19:29
Student: Drashti
Batch: Dec25
Client name: Mr. Ramesh
Age: 65 years
Gender: Male
Marital status: xyz
Education: xyz
Occupation: xyz
Residence: xyz
Religion: xyz
Socio-economic status: Middle
Handedness: xyz
Identification marks: no
Disability / Medical issues: no
Source of referral: Self
Relationship with informant: none
Chief complaints:
1. Hear voices as soon as he is going or asleep 2. Because of which he cant sleep, resulting in tiredness
Presenting concerns:
The old man all living by himself is unable to sleep properly because he keeps hearing the voices and is tired in need of desperate help. He did not report that anyone is controlling him or putting thoughts in his mind.
Client verbatim statement:
“Doctor, at night, just before I fall asleep, I hear people abusing me. Because of that my sleep gets disturbed.” “I’m tired, I just want to sleep.”
A – Affect / Emotion
Seemed genuinely distressed, not angry or suspicious toward the clinician. Appeared anxious and fatigued
B – Behaviour
mild shakiness in his hands, worried, tired look, he looked tense and sleep-deprived. His speech was normal in rate and tone
C – Cognition
He was oriented to time, place, and person, but his attention seemed a little reduced, likely due to poor sleep. When you asked what he thinks is happening, he admitted he is not sure, but he knows it is not normal and wants help, showing limited-to-fair insight.
D – Daily functioning
Sleep was major factor which was affected very badly.
Onset details
Considering the possible medical or neurological factors and medication side effects it can be said that experience sleep-onset auditory phenomena (hypnagogic experiences)
Course details
Continuous
Predisposing factors
Possible medical or neurological factors
Precipitating factors
Medication side effects
Perpetuating factors
None
Protective factors
None
Present maintaining factors
Possible medication side effects
Family history
xyz
Personal history
xyz
Educational history
xyz
Vocational / occupational history
xyz
Sexual and marital history
xyz
Forensic history
xyz
Suicidal / self-harm / substance use history
No self harm and willingness to get out of the situation
Living conditions
Alone
Premorbid personality
Neatly dressed and polite in his manner of speaking, oriented to time, place, and person
1. basic sleep hygiene 2. stimulus control: keep a regular sleep-wake schedule, 3. avoid long daytime naps, 4. reduce caffeine late in the day 5 .avoid lying awake in bed for long periods. 6. simple bedtime relaxation routine like slow breathing and muscle relaxation. 7. suggested bringing a caregiver or family member next time for collateral history, and advised monitoring for daytime symptoms or decline in functioning.
Summary: (not filled)
(no extra notes)