CLINICAL REPORT

Personal Bio Data

● Name: ABC
● Father’s Name: EFG
● Age: 48
● Sex: Male
● Religion: Islam
● Birth Order: 4th among 7 siblings
● Siblings: 7 siblings
● Education: Primary school graduate
● Occupation: Construction Worker
● Monthly Income: 25-35 thousand per month
● Marital Status: Married
● Father Living/Dead: Deceased (liver disease)
● Mother Living/Dead: Living (Hypertension)
● Socio-economic Status: Lower class
● Address: XYZ

Source of Referral and Presenting Complaints (Verbatim)

● Source of Referral: Referred by a general practitioner for evaluation due to

worsening liver function and digestive issues.
● Presenting Complaints:
The patient presented with abdominal pain, bloating, vomiting (especially after
meals), frequent nausea, loss of appetite, dark-colored urine, pale stools, and
significant weight loss. He also complained of constant fatigue and reported that
his abdomen has been swelling, particularly on the right side, where the liver is
located.

Presenting Complaints (Reported by Patient)

● Symptoms:
○ Abdominal pain (upper right side)
○ Bloating
○ Nausea and vomiting (especially after meals)
○ Loss of appetite
○ Fatigue
○ Dark-colored urine
○ Pale stools
○ Significant weight loss
● Duration: Symptoms started about four months ago and have been worsening
over time.

History of Present Illness

The patient has been experiencing liver problems for the past four months, including
nausea, vomiting, and abdominal pain. His condition worsened over the past two
months, with loss of appetite, dark urine, and weight loss. He also reported bloating and
swelling in the abdomen, indicating possible liver cirrhosis. The patient has been a
smoker for 20 years, which may have contributed to his liver problems. He also
admitted to occasional alcohol use in the past but stopped drinking a year ago after
noticing early symptoms.

Family History

The patient’s father passed away due to liver disease, and his mother is living with
hypertension. There is a history of chronic illnesses such as diabetes and hypertension
in the family, but no known psychiatric history.

Family Psychiatric and Medical History

No known psychiatric history, but the patient’s family has a significant medical history of
liver disease and hypertension.

Personal Medical History

The patient was relatively healthy until four months ago when he started experiencing
symptoms related to liver disease. He has been a smoker for 20 years and occasionally
used alcohol in the past, but he stopped drinking a year ago after noticing early signs of
liver dysfunction.

Personal History

● Childhood: Grew up in a lower-class family with limited education. No significant

childhood illnesses.
● Adolescence: Lived a healthy life with no major medical concerns.
● Adulthood: Developed liver problems in his late 40s, following years of
smoking and occasional alcohol use. He has been experiencing fatigue,
abdominal swelling, and digestive issues over the past several months.
Family Environment

The patient lives with his wife and three children. He reports a supportive family
environment, though the financial strain caused by his illness and inability to work has
been a source of stress for him and his family.

Premorbid Personality

The patient described himself as a hard-working and responsible individual before his
health began to deteriorate. He is now more frustrated and anxious due to his declining
health and financial concerns.

Psychological Assessment

● Clinical Interview: The patient was cooperative during the interview but
expressed anxiety about his worsening health and the financial burden it has
placed on his family. He mentioned feeling guilty about his past alcohol use and
worried about how much longer he will be able to support his family.
● Mental State Examination:
○ Appearance: Tired and visibly weak. Slight abdominal swelling.
○ Attitude: Cooperative but anxious and concerned about his health.
○ Speech and Language: Normal speech but slow due to fatigue.
○ Mood: Anxious and worried, particularly about his financial situation.
○ Suicidality and Homicidality: Denied any thoughts of harm to self or
others.
○ Attention Span: Intact.
○ Behavior: Cooperative, no unusual behaviors observed.
○ Level of Consciousness: Alert and oriented to person, place, and time.
○ Orientation: Fully oriented.
○ Thought Process/Form: Logical but occasionally preoccupied with health
concerns.
○ Affect: Anxious but congruent with the situation.
○ Insight and Judgment: Good insight into his health problems.
○ Intellectual Functioning: Average.
○ Thought Content: No delusions or obsessions noted.
○ Memory: Good memory, intact for both recent and remote events.
Psychometric Administration

The Beck Depression Inventory (BDI) was administered to assess the emotional
impact of his worsening liver condition and financial concerns.

Interpretation of Test Results

● Beck Depression Inventory (BDI):

○ Cutoff Score: 0-13 (Minimal), 14-19 (Mild), 20-28 (Moderate), 29-63
(Severe)
○ Raw Score: 17 (Mild depression)

The patient’s BDI score of 17 indicates mild depressive symptoms, likely related to the
stress of managing a chronic illness and the financial strain it has placed on his family.
He also expressed guilt over his past alcohol use and is anxious about his prognosis.

Qualitative Analysis

The patient’s mild depression is likely linked to his worsening liver condition and the
financial burden caused by his illness. Despite quitting alcohol a year ago, his liver
function has continued to decline, leading to anxiety, frustration, and concerns about his
family’s future. His supportive family is a protective factor, but the physical and
emotional stress of his illness is significant.

Case Formulation

The client is a 48-year-old male with worsening liver disease and a history of smoking
and occasional alcohol use. His BDI score of 17 suggests mild depression, primarily
due to his declining health and financial concerns. The patient is experiencing
symptoms such as abdominal pain, nausea, vomiting, and fatigue, which have impacted
his ability to work and provide for his family. He also reports anxiety and guilt about his
past lifestyle choices.

Prognosis

The prognosis is guarded, given the patient’s worsening liver condition. However, his
mild depressive symptoms can be managed with psychological support. Continued
medical follow-ups and lifestyle changes will be essential in managing his liver disease.
Recommendations

1. Psychological Support: Regular therapy or counseling to help the patient cope

with his mild depression and the emotional burden of his liver disease.
2. Health Education: Provide information about liver disease management and the
importance of maintaining a healthy lifestyle to slow disease progression.
3. Family Counseling: Encourage family involvement in therapy sessions to
provide emotional support and help the family cope with the financial strain of the
patient’s illness.
4. Medical Follow-Up: Ensure regular medical follow-ups to monitor the patient’s
liver function and manage symptoms such as abdominal pain, nausea, and
fatigue.
5. Stress Management Techniques: Introduce relaxation exercises or stress
management techniques to help the patient cope with his anxiety and improve
his overall mood.