Long Case Presentation in Psychiatry

1. Case Presentation
Dr Aziz Mohammad
PGT Psychiatry KTH

2. Demographic Details
Said Mohammad, 18 years old, single,
educated upto 6th class, resident of Mula
Zai Warsak Peer Bala Peshawar.

3. Chief Complaints
• Suspicious, Aggressive, Sleepless, Not eating :
3 days:
• Social Withdrawal: 1 month

4. History of Present illness
• According to the father of the patients, patient
has started avoiding mixing with family
members for the last one month, and has
started expressing that the whole family has
been plotting against him and trying to kill him
for the last three days.
• He would become aggressive without any
significant provocation, and physically attack
those who try to confront or take him for any
sort of treatment for his abnormal thoughts.

5. HOPI (cont..)
• He is sleepless and has stopped eating and
drinking in home with a belief that his family
members may poison him.
• Soon after developing these symptoms his
parents and siblings thought he was been
possessed by Jinnat, and he was taken to
spiritual healer for treatment two times before
they decided to bring him to hospital.

6. HOPI (cont..)
• His parents decided to take him to KaKa Saib
Zyarat after no response to the treatment of a
local faith healer. While on way near pabbi the
patient jumped from the motor cycle on which he
was being carried by his father and mother. Luckily
they received no major injuries. He started fighting
with his parents again with those thoughts of
being taken to be killed. He was then taken in a car
with a help of his brothers after a non successful
attempt by his father in the pabbi bazar where the
father reports many people witnessed them
pulling each other.

7. HOPI (cont..)
• After returning from Zyarat the patient showed
no improvement in his condition, and he was
brought to hospital at 11’o clock on Saturday
night against his will restrained by 4 attendants
on a stretcher with his hands tied together.
• The brother of the patient reports that they
noticed change in the behaviour of the patient
over the past one month when the pt became
socially withdrawn and aloof with no interest in
matters related to him and his family.

8. HOPI (cont..)
• The only recent stressor which could be
identified is the shifting of the family from
their native village Jamrud to Mula Zai (Peer
Bala warsak road) about two months ago due
to personal security reasons. His father is a
driver in army and reports his home was easily
accessible to terrorists in Jamrud. All the
family members are strangers in the new
village with no friends and relatives.

9. HOPI (cont..)
• There is no history of fever, fits or grossly
disorganized/confused behaviour.
• No history of any self
talking/muttering/smiling was reported .
• There is also no history of any mood
symptoms.

10. Past History
• Patient has history of diarrheal illness which
remained for 3 months before it could be
successfully treated 4 months ago.
• For his diarrhea He was investigated In
Gastroenterology OPD HMC and found to have
mesenteric lymphadenopathy on U/S Abd
• Stool R/E was reported normal.
• He was treated with inj:Ceftriaxone 2gm OD, for
one wk on outdoor basis, with which he recovered
and his diarrhea subsided. (record available)
• There is no past psychiatric or surgical history.

11. Family History
• Father: Healthy, no formal education, Driver in
army for the past 24 years.
• Mother: Healthy, house wife
• Sib: 9 brothers and 1 sister. Most of his siblings are
not educated and working as labourers on daily
wages basis.
• B/O: 3rd.
• Satisfactory interpersonal relationship with the
family members.
• No history of any psychiatric illness in first or
second degree relatives.

12. Personal History
• NVD, with No history of prenatal, or post natal complications.
• Achieved his DMS at appropriate age.
• No history of separation from parents, or any sort of abuse reported
during early and late childhood.
• No history of conduct problems or neurotic traits during childhood.
• Started going to school at age 5. Left school in 6th class, as he did not
have interest in going to school further.
• Never done any job in his life time, apart from being an assistant for
a month with his brother who is a Pick Up Driver. His father reports
he would be roaming around aimlessly and would show no interest
in doing any work.
• He is Single, and not engaged
• There is No history of any drug abuse or encounter with police or
law.

13. Pre-morbid Personality
• Father and brother described him as sociable,
he has quite a few friends in his old village.
• Used to have adequate coping skills under
stressful conditions.
• Would give importance to cultural and
religious norms.
• Would spend his leisure time with his friends

14. Physical Examination
• GPE : He was dehydrated, with sunken eyes,
dry mouth and reduced skin turgor.
• BP: 110/70 mm Hg, pulse: 94/min, T: 98F
• No Jaundice, Oedema, Lymphadenopathy,
Cluddbing, or Aenmia.
• CVS: No added heart sounds.
• Chest: Clear, VB.
• Abd: Soft, Non tender with no visceromegally

15. CNS Examination
• Patient was uncooperative and resisted to be
examined at all.
• He would make his body stiff whenever some one
would touch him and would not let the hand of
examiner go beneath his head by extending his
neck, pressing his head against the pillow, so neck
stiffness could not be elicited. His deep tendon
reflexes were brisk in all 4 limbs.
• His motor/sensory systems and gait could not be
formally assessed, but there were no evidence of
any focal motor deficits, as his would contract any
part of his body when touched for examination.

16. Investigations
• FBC: TLC 7800, N:60, L:30, ESR :10
• CXR: Clear Lungs fields, No Hilar pathalogy
• LFT: AST:30,
• Urea:60, creat: 0.7
• HbsAg/Anti HCV: non-reactive
• S. Electrolytes: Na: 145, K:3.5, Cl:105
• RBS: 78
• MRI Brain: Normal

17. MSE
• A/B: A boy of apparantly 18-20 years, lying in
bed, with a torn qamees, and bruises on his left
side of forehead and left hand, not responding to
questions or commands, resisting to be
examined. No rapport or eye contact could be
established or maintained.
• Mood: Obj: Flat
• Speech: Mute
• T/P: hallucinations and delusions could not be
formally elicited, the pt exhibited paranoid
behaviour,
• Cognition could not be tested.
• Insight: Absent

18. Differential Dx
On the basis of history and MSE, 1st preferable
diagnosis according to ICD-10 on Axis 1.
• (F23): Acute and Transient Psyhotic Disorder with
its sub category
(F23.3): Acute Predominantly Delusional
Psychotic Disorder
DDs include:
(F06.2) Organic delusional [schiphrenia like]
Psychosis
(F10-19): Mental and Behavioural disorder due
to psychoactive substance abuse (F1x.0) Acute
Intoxication.

19. DDs (Cont..)
• On Axis ll (disabilities).. Score 1-5
• Personal Care: 5
• Occupation: 5
• Family and House Hold: 5
• Broader Social Context: 5
• On Axis lll (contexual factors)
• Recent migration of the family

20. Management
• Immediate:
• Patient was admitted in psychiatry ward
• He was rapidly tranquillized due to his mental
state at the time of his arrival.
• Short Term:
• He was assessed in detail in the morning on
Sunday, with his full physical examination. His
father and brother were interviewed about the
onset, course and nature of his symptoms.
• His routine investigations were sent.

21. Management (cont..)
• Short Term (cont..):
• He was given Inf: Dextrose W 5% 1L iv stat and
• Inj: Haloperidol 5mg x2 amp IM BD
• Inj: Diazepam 10 mg IV BD.
• His father and brothe were provided with
informational care, about the nature of the
illness and its management.

22. Management(cont..)
• Medium Term:
• 4 hourly Monitoring of the patients BP, temperature,
intake and output record was maintained.
• Was found to have no urine output for 2 days before
admission with inadequate oral intake, he was given
inf; R/Lactate 1L i.v stat and then OD, soon after
receiving the infusion the pt passed urine.
• He was non communicative, uncooperative, and detail
CNS examination could not be done in detail even on
3rd day of admission.
• Liaison was made with medical ward to rule out the
possibility of organic cause for his current condition.

26. Management(cont..)
• Medium Term (cont..)
• Patient was started on
• Inj: Aclova (Acyclovir) 500 mg iv TDS
• Inj: Gen-M (Artemisunate) 2gm iv OD.
• Tab: Olanzapine 10 mg OD (nocte)
• The investigations advised along with MRI
brain was done, which came out to be normal.

27. Management(cont..)
• Medium Term (cont..)
• Serial MSE
• PANSS scale was applied with scores of (P:35,
N:24 and G:40, total: 99)
• 1st episode Psychosis proforma attached and
filled.
• Temp/BP monitoring 6 hourly
• Monitoring for any afverse effects of
medication

28. Medium Term (cont..)
• Medium Term (cont..)
• Patient has shown improvement, and has
started taking food and fliud orally, with
marked reduction in his paranoa, although
prefers to talk very less his speech is relevent.
His sleep is normal. Has not developed any
EPS.

29. Prognosis
• Short Term: acute onset, short duration, positive
symptoms and good early response to
antipsychotics are all in favour of good short term
outcome.
• Long Term: Due to male gender, young age, poor
educational background and premorbid
dependent nature of patient the long term
prognosis will depend on adherence with
treatment and his social support and is guarded
at the moment.