Case History – Training Record

Chief complaints:

as soon as he goes to sleep, he hears people abusing him when everything is quiet and lights are off

Presenting concerns:

the client hears people abusing him when he goes to sleep or when everything is quiet and lights are off. this disturbs his sleep, which causes him tiredness and fatigue

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

worried

B – Behaviour

mild shakiness and tired

C – Cognition

orientation; normal attention; little less memory; clear consciouseness; responsive

D – Daily functioning

lack of sleep

Onset details

subacute, during night mostly

Course details

continuous

Predisposing factors

medications

Precipitating factors

medications side effects

Perpetuating factors

none

Protective factors

none

Present maintaining factors

maybe medications

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, knows the problem and is ready to fix it

Living conditions

xyz

Premorbid personality

neatly dressed, looked his age, polite