Case presentation bhadra twenty five.pptx

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1. Case presentation Presenter Dikendra Sanjyal Department of psychiatry NMCTH,Birgunj 2081/05/25

2. Patient particulars Name: Miss RK Age: 18 years Sex: Female Religion: Muslim Education: Studying in class 12 Occupation: Currently unemployed Marital status: Unmarried Socioeconomic Status: Lower middle class Family type: Nuclear Address: Birgunj DOA- 1 st Aug 2024 DOE-1 st Aug 2024

3. Source of referral: Family members Source of information: Patient herself Mother: Mrs. U.K, 40 year, married, Secondary level, Homemaker by occupation, has stayed with the patient during entire period of illness Information provided is reliable and adequate

4. Chief complaints According to the patient: Consumption of soil, brick for 15 years Headache for 6 year Low mood for 6 years According to informant: Persistent eating brick,soil,Ashes for 15 years Headache for 6 years Restlessness for 6 years Low mood for 6 years

5. Total duration of illness: 15 years Onset was insidious Course was continuous Predisposing factors: Positive family history of psychiatry illness in her father and elder siblings Precipitating factors: Psychological trauma Perpetuating factors: could not elicited

6. History of presenting illness: According to the informant, she was apparently well 15 years back. One day the informant noticed that the patient was eating soil and other non-food substances while playing in the ground. She didn't pay any attention at the time. The informant thought that she was too small to distinguish between edible and non-edible food.

7. The days went by, and when she was about 10-12 years old, the informant found her maximum time with eating soil,clay,brick and ash . By this time, she would be able to do household chores; she was reading in class six in a private school and did well in her studies. She would go to the market to make small and large purchases and had knowledge of distinguish the things which are for eating and not eating.

8. T he informant used to allegedly beat her by telling her not to eat bricks, soil, and ashes whenever she used to find her during eating this substances. But the patient didn't listen to her, and whenever she saw the earth, brick, and ash, she had a strong crave to eat that kind of substance. She said that it was difficult for her to control eating because she felt restless, characterised by a rapid heartbeat which persisted for some time and only relieved after eating that non nutritive things. She had knowledge of eating this substance can causes harmful health problems but she never left to eat such substances.

9. Due to eating non nutritive substances behaviour, she had to visit clinic due to sudden onset of pain in the upper quadrant of the abdomen, diffuse in nature, lasting from several hours to a day, occurring at intervals of 2-3 days. This pain was relieved by taking medication, and she had difficulty functioning.

10. How often did the informant scold her for not eating such a substance? When asked, the patient replied, "She had a sudden urge to eat such a substance and had difficulty controlling this urge . It was continuous in nature but whenever she had stressor related to academic at that time she used eat more than usual day. Despite the regular consumption of non-nutritive substances, the patient had regular appetite, sleep, and bowel and bladder control

11. Six years ago, there was a pandemic of the Corona virus and there was a lockdown. At that time, the grandfather of the patient had a sudden onset of a fever. The fever was unrecorded at the time. It was accompanied by a dry cough and difficulty breathing. The family members then suspected that he was suffering from Corona. They took him to NMCTH, where he was admitted.

12. For the treatment of the grandfather, all the family members were present in the hospital. The patient was alone in the house. At that time, one of the recognised neighbours suddenly came into her house and tried to physically assault her. He threatened her not to tell others and that he would tell everyone in the village. The patient couldn't control herself. She cried for a long time in the house. In the evening, her family members returned home and saw her face as sad. She did not communicate well with other family members. When they asked the patient what the reason was, she didn't answer and was in tears for some time. Then the family members didn't bother her. They thought it was part of her grandfather's illness.

13. The patient didn't tell anyone about the event and spent time alone in the room. She didn't communicate with other family members, as she used to communicate well with other family members. Most of the time was spent thinking about what happened. She didn't have sleep at night and had difficulty with sleep onset. She would keep thinking about the event, which would often make her want to roll and toll over bed. At 12-1am, the patient would fall asleep and wake up at a regular time in the morning.

14. The patient didn't respond immediately when called by friends and teachers in the school, and they had to call several times to respond, and previously the patient would respond in one call and used to share small things with friends and spend time with friends and family members.

15. When others saw this kind of behaviour from the patient, they would try to console her, but she wouldn't respond and would go out of the house. The patient used to get anxious thinking that this event would happen again and would be restless. She would have repeated flashbacks of this event day and night. While sleeping, the patient saw the dream and woke up between sleeps, leading to disturbed sleep. In school, she had flashbacks of events and got anxious. While having a flashback of the event, she didn't interact with others. The flashback was persistent and continuous.

16. While walking in the street and at school, the patient used to get anxious by thinking about the events and didn't communicate with others at that time . After 2 years of the event, the patient shared all the things with her mother and started to cry in front of her. During this period, the patient was able to talk to her mother about the event and had difficulty forgetting it. She had also thought that life would be better after death, but she never tried it.

17. Day by day, the patient's performance at school deteriorated as she had difficulty concentrating on her studies due to a disturbing flashback. This flashback was clear as water, vivid, and occurred at any time and leads to crying and sometime tearful eyes. She failed in class 10. Previously, the patient had studied regularly and was an average student who had never failed an exam.

18. With these symptoms, the patient visited the NMCTH and was prescribed a capsule of fluoxetine 20 mg per day and a tablet of olanzapine 5 mg per night. She improved by 70-80% with regular medication for 4 months, after which she stopped the medication.

19. A few days later, the patient had a sudden onset of headache involving one side of the head, throbbing in nature, lasting 1-2 hours, radiating to the other side of the head, associated with dizziness and tearing from both eyes, and difficulty seeing the near object, which usually occurred while she was having a flashback of an event. After consultation with a respected department, she used glasses and improved.

20. She became irritable with members of her family, and this irritability usually came on when someone was trying to ask her a question. As a result of this flashback, the patient began to check the door repeatedly at night, and when asked, the patient replied, "If I don't lock the room, the neighbour will come in the absence of family members, and this event will happen again.

21. She thought that all men of this gender would do this to her, so she didn't communicate with her male friend after that. She started taking her medication irregularly again for 1 year. Her headaches made it difficult for her to fall asleep. She would eat non-edible substances until now and was admitted to the psychiatric ward for better management.

22. Negative history No h/o headache, fever, vomiting, head trauma No h/o use of any psychoactive substances No h/o overfamiliarity, talkativeness, distractibility, hyper religious behavior No h/o chest pain, difficulty in breathing, palpitations, feeling of impending doom No h/o distressing thoughts or repetitive actions No h/o seeing things which is not seen by others and hearing of voice which is not heard by others . No history of someone had taken his thoughts from his brain or someone had inserted thoughts in the brain.

23. Treatment history Mention in HOPI.

24. Past history No h/o hypertension, diabetes mellitus, pulmonary tuberculosis or thyroid disorder No h/o any surgical illness or procedures No h/o any other psychiatric disorders Difficult in seeing near vision for 2 years and under treatment.

25. Family History: +VE PSYCHIATRY ILLNESS IN FATHER Mother Grandfather died due to aging at 70 years Grandmother died due to aging at 67 years +VE PSYCHIATRY ILLNESS

26. Patient’s belonged to nuclear, Lower middle socioeconomic status of Muslim. Her family consisted of father, mother and 5 children including her . Siblings: Eldest sister: Miss YJ. Ansari 25 year old, studying in Bachelor level has symptoms of suggestive of schizophrenia, no medical and surgical illness and has staying with patient. Eldest brother : Mr SA. Ansari 22 year old, educated up to 8 th class, worked as mechanic in garage, has been staying with patient and primary breadwinner of the family.

27. Youngest brother: Miss SJ. Ansari 15 year old, studying in class 9,unemployed, has been staying with patient and know about her illness. Patients father: Mr SJ. Ansari, 53 years old married Muslim, Labour by occupation, educated up to primary level, has symptoms suggestive of schizophrenia under medication for 2 years and Head of the family and primary breadwinner. Patient mother : was primary care giver.

28. IPR among family members-good except with her father due to illness. IPR between family members and patient –good Family members support her fully both emotionally and financially No history of continuous stressor in the family No history of medical/surgical illness in the family

29. PRESENT LIVING SITUATION Own pucca house No overcrowding Well and adequate ventilation with proper sanitation

30. PERSONAL HISTORY Birth history Ante-natal History Planned and wanted pregnancy No h/o Medical illness (Diabetes/ HTN Jaundice /STD) No h/o hyper-emesis, 1 st trimester X-ray exposure, drug intake (other than folate, iron, calcium) or psychotropic, alcohol or tobacco use Irregular ante-natal visits and immunized with 2 doses of TT USG was done and no abnormality found No h/o complications such as Rh incompatibility, twin pregnancy, threatened abortion , Bleeding, Pre- eclampsia , Eclampsia Fetal movements were perceived throughout the pregnancy (not excessive or sluggish)

31. Natal history Born at the home via NVD at term. Presentation :? longitudinal, cephalic No h/o large head, low placenta, prolapsed cord, cord around neck, fetal distress, prolonged labor, PROM, non-progress of labor, or meconium stained liquor, excessive bleeding

32. Neonatal and post-natal History Birth weight could not be remembered , cried immediately after birth, color : Pink No h/o Respiratory distress Activity Normal, Suckling Normal Feeding : Breast fed exclusively for initial 6 months : on demand No feeding problem No abnormalities in Urine/ stools No congenital anomalies/ stigmata noticed No h/o Neonatal seizures, Jaundice, Infection, Hospital stay Immunized according to Immunization program of Nepal, documents not available

33. Developmental history : Informant didn’t know exact time of milestones achieved but said there was no developmental delay and achieved all the milestones as compared to other siblings.

34. Childhood and adolescent history She used to spend most of his time playing with her friends. H ad no difficulty getting involved with new people. Used to get angry often with friends while playing but did not use to get involved in physical fights. No h/o serious childhood illness requiring medical attention. No h/o behaviors such as nail biting, temper tantrums, or bed wetting . No h/o Bruxism/ sleep walking/ limb movements, Nightmares and night terror.

35. Play Preferred group play with her siblings and cousins, she mixed well with other children from her class No indifference towards playmates or siblings No h/o inappropriate intrusion or impulsivity during play Understood games governed by rules Showed co-operation during play Did not bully other children Did no get bullied by other children

36. Education Type of schooling: day-government School Nature of school: Normal Any literacy exposure before formal schooling? No. Started schooling at approximately 4-5 years Class 1-8: in her village private school Class 9-12: in her village in government school, changed school due to financial problem Average in study After that event the performance in higher class was decreased and fail in one subject in class 10. No history of disciplinary action in school Attendance: Regular Peer group adjustment: average Problems with teachers: Nil Class room behavior: Favorable, no altercations with peers or teachers

37. Occupational history : currently unemployed Menstrual history: Menarche : 12 years Regular cycles, 30 +/- 3 days Flow: 4-5 days, uses 3-4 pads/day No h/o dysmenorrhea, menorrhagia L.M.P . :29 July 2024

38. Relationship and sexual history: Identifies as a female at age of 5 years, attracted to males Had no relationship till now No specifies fantasies were told by patient History of physical abuse at age of 12 years Other couldn’t be elicited as patient didn’t say on asking further.

39. Marital history : unmarried No history of drugs and substance use

40. Premorbid Temperament Activity level: Regularly went to school Wake up at 7 Am She became ready for going school at 8 AM 9:00 Am had food 9:40 Am went school by herself 4:00Pm return from school 4-5 Pm had breakfast 5-7 Pm goes to play games with her friend 7-8 Pm did homework 8:00 Pm had dinner 9:00Pm went for sleep in bed Impression – energetic+

41. Persistence and attention spans: She completed homework by herself in one seating after playing with her friends. Impression – immersed+ Distractibility : Could focus on homework even with surrounding noise and activity. Impression – Attentive+

42. Sensory threshold: When doing homework and watching TV, she was not annoyed when family members talk loudly and able to complete tasks Impression – Unaffected + Mood : When patients stayed with mother and father she would often spend time talking to her mother and helping her around the house during activities. Impression - Positive

43. Rhythmicity: Patients slept and wake at similar time everyday but some times had to told to sleep on time, meals was at regular time and bowel habits are regular Impression – Regular+ Approach : When meeting new people or guests at home,she greets them without being told Making friends is easy and mixed well with everyone in class peers and other family members Impression – Withdrawal (open)

44. Intensity: When guests and family members visited she often was cheerful and greeted them Impression – Exuberant+ Adaptability: She is not fussy when things are not to her liking like meals and tends to eat whatever is given to her. Impression- Accommodating Overall impression – Easy child

45. GENERAL EXAMINATION Date of admission: 1 st Aug, 2024. Date of examination : 1 st Aug, 2024. Weight: 48Kgs Height: 5feet, 3 inches ( 163cms ) BMI: 20.22 kg/m2 Vitals: Temperature: 98F Pulse: 78/min Respiration rate: 15breaths/min SPO 2 : 98% in room air BP: 110/80 mm/Hg Pallor/Icterus/Lymphadenopathy/Cyanosis/Clubbing/Dehydration: Not seen SYSTEMIC EXAMINATION: Cardiovascular: S1S2M0 Respiratory: B/L Vesicular breath sounds, no added sounds Gastro-intestinal: Soft, non tender, no organs palpable, Bowel sounds 3/min

46. NEUROLOGICAL EXAMINATION Cranial Nerves: Olfactory: smell senses: Intact Optic: Visual Acuity 6/6 Pupil 3mm equal B/L, circular, reactive to light Fundus Examination: Color/ shape/margin/ cup- Normal Oculomotor , Trochlear, Abducens Eyeball central in position, gaze intact in all directions Trigeminal: Muscles of mastication: intact Sensation over face: intact Corneal reflex: intact

47. Facial nerve: Facial symmetry and movement of the face: intact Taste in anterior two-third of the tongue: intact Vestibulo -Cochlear: Rinne’s test: AC>BC Weber test: Not lateralised Glossopharyngeal and Vagus : Uvula-centrally located Gag Reflex: intact Cough on Command: intact Spinal Accessory: Trapezius and Sternocleidomastoid: shrugging: intact Hypoglossal: Inspection of tongue and tongue movements: Intact

48. Motor System: Muscle bulk: B/L equal Involuntary movements: not present Muscle tone: Not increased or decreased Muscle power: 5/5 over all limbs Sensory: Light touch: Intact B/L equal Pain: Intact Temperature: Intact Vibration: Intact Joint position and movements: Intact

49. Reflexes: Biceps: Normal Triceps: Normal Brachioradialis : Normal Knee: Normal Ankle: Normal Abdominal: normal Cremasteric : Normal Plantar: Flexion

50. Cerebellar signs: Nystagmus : not present Scanning speech: not present Intentional tremors (finger-nose test): Normal Heel-shin test: Normal Dysdiadochokinesia : Normal Rebound phenomenon: Normal Pendular knee jerk: Not present Tandem walking or ataxic gait: Normal

51. Cortical signs: Tactile localization: normal Two-point discrimination: normal Stereognosis : normal Graphesthesia : normal Meningeal Signs: Neck rigidity: not present Kerning’s Sign: not present Brudzinski Sign: not present Impression: No neurological deficits were noted

52. MENTAL STATUS EXAMINATION GENERAL APPEARANCE AND BEHAVIOUR An average mesomorphic built female appear to be in late ten’s which was appropriate as stated, Wearing a khurta suruwal which was appropriately dressed according to sex, climate and culture, well kempt hygiene and well groom, No abnormal gait was noted, No abnormal facial expressions and Abnormal movements absent, on Greeting replied Salam walikum , Eye contact was initiated and maintained , Attitude was cooperative , Psychomotor activities was neither increased or decreased, No catatonic behavior noted and Rapport was Established.

53. Speech: Spontaneous , Coherent, Comprehensible Language : Hindi and Bhojpuri Rate: average Tone: Normal Pitch: Normal Volume: Normal Reaction Time: neither increased nor decreased

54. Mood/Affect: Subjective= Q: तपाई को मन कस्तो छ? A: राम्रो छ। Objective= Quality : Euthymic Range : Broad Fluctuation : not present Reactivity : present Congruent to Thought: present

55. Q. तपाई आफ्नो घर को बारेमा केहि भनु होस् ? A . मेरो घर यहि बिरगंज मा छ। घर मा बुवा,आमा, दिदि, भाई हरु छन्। सबै घर मा मिलेर बस्छ। मेरो दिदि ले पनि मानसिक को औसदी खानु हुन्छ। Q. तपाई आफ्नो मन पर्ने चाडपर्ब को बारेमा भनु होस् ? A . मलाई मनपर्ने चाड पर्ब इदी हो। इदी मा सबै परिवार वसेर खान पहिन्छा। लामो समय रोजा वसेर त्यो दिन मिठो परिकार हरु खान पाहिंछा।

56. THOUGHT: Form : Derailment/ LOA: Not present Circumstantiality/ Tangentiality : Not present Neologism: Not present Word Salad: Not present Flow : Tempo: Flight of Ideas/Retardation: Not present Continuity: Block : Not present / Perseveration: Not present

57. Q: के तपाइलाइ वोरिपरि को मान्छे ले तपाइ को बारेमा कुरा गर्छन जस्तो लाग्छ । A: लाग्दैन। Q: के तपाई लाई लाग्छ जादू टूना गरेर तपाई लाई बस मा गरेको जस्तो लाग्छ । A: लाग्दैन। Q: के तपाइलाइ ओरिपरि को मान्छे ले तपाई को बारेमा कुरा गर्छन जस्तो लागछ ? A : लाग्दैन।

58. Q: कैले काई हजुर लाई जीवन बेकार छ , बाचेर के गर्नु लाग्छ ? A: मलाई सदै लाग्छ मेरो जीन्दगी बेकार हो बनेर र यो जीन्दगी संग बाच्न्नु भन्दा मर्न पाए भनेर सोच आउछ। Q: तेस्तो सोच कति भेला आउछ? A: मलाई सदै आउछ। Q: अनि तपाई ले आफ्नो मर्ने को लागि केहि सोच भनउनो भयको वा सोच्नु भयको छ अगाडी ? A: छैन तेस्तो। Q: तपाई लाई मर्नु को सोच आउनु मुखे कारण के हो ? A: मलाई आज भन्दा ६ बर्षे पहिले मलाई गाऊको मान्छे ले नराम्रो गरेको थियो। तेसैले गर्दा मलाई हरे समय त्यो कुरा मात्र आउछ र मलाई अरु संग बोल्ने पनि डर लाग्छ। अनि कसरि यो कुरा अरु लाई भने र यो समाज ले मलाई के भन्छ होला यो कुरा थाहा पाया पछि भनेर मेरो मन उदाश हुन्छ।

59. Q: के तपाई लाई कुनै चिज वा कार्य गरेको पक्का हुदा पनि काम ठिक छ छैन भनि दोहेरयरा हेर्ने गर्नु हुन्छ? A: मलाई डर लाग्छ रति अनि घर मा कोठा भन्दा गरेकी भनेर हेर्न जान्छु। Q: के को डर लाग्छ ? A: तेही घटना फेरि हुन्छ कि भने। Q: त्यो सोचे सदै आउछ कि ? A: आउछ अनि मलाई डर लाग्छ। Q: तपाई सफा सुन्दर हुदा पनि बारेम्बार धेरै बेर लागेर लुगा धुने , नुहाउने अर्थार्थ सरसफाई बिशेस समय दिने गर्नु हुन्छ ? A: छैन तेस्तो।

60. Content : Passive death wish + Preoccupied by stressor/event No delusion of persecution, reference No obsession

61. Q. तपाईं लाई लाग्छ कि तपाईं को सोच आफ्नो हैन र कसैले दिमाग मा सोच राख्दियको हो जस्तो लाग्छ ? A : लाग्दैन Q: तपाईंलाई लाग्छ कि बाहिर सक्ती ले तपाईं को सोचे लाई निकालेको जस्तो लाग्छ ? A: लाग्दैन Possession: No thought insertion, no thought withdrawal

62. Perception: Q. तपाइ एक्लाई बसेको बेला कानमा मा आवाज आउछ ? A : आउदैन । Q: अरु ले नदेखेको चिज तपाईंले मात्र देख्नोनु हुन्छ ? A: देखेदिना । Q: के तपाईं लाई आफ्नो वोरिपिरि को चिज साचो हैन जस्तो लाग्छ ? A: लाग्दैन । Impression: No hallucination and derealisation.

63. Cognition : Orientation: Time : Period of day: Afternoon Estimated time: 2 pm Day: Thursday Date : 01-Aug 2024 Season: Summer Place: Country : Nepal City: Birgunj Place: National medical college Floor : first Ward : Psychiatry Person : Identity of accompanying informant asked, identified as mother with correct name Impression : Oriented to time,place and person .

64. Attention: o Digit forward: 4 DF o Digit Backward: 3 DB Concentration: o Serial subtraction : Could do 100-7 upto 3 and then did mistake In 40-3 did all without any mistake and took 1 minutes In 20-1 did without any mistake and took 15 second o Name of weeks :Could able to name the weeks and its reverse. o Name of months & its reverse: Was able to do Impression: Arousable and Sustained

65. Memory o Registration and Recall (3 words): Intact i.e ( सर्प , कलम र नदि ) o Immediate: Recall after 5 minutes in same order. o Recent : Confirmed breakfast: Intact o Remote: Year of birth : correctly confirmed Impression: Preserved

66. Intelligence: o Q : ( Young girl handling an unexpected guest at home in absence of other family members) o A: welcomed the guest. o Simple calculations: could able to perform multiplication i.e 2* 3=6 o Complex calculation: patient was asked if you buy 10 apple in cost of 50? What would be cost of each apple? The patient replied correctly i.e 5. o Information and Fund of knowledge: Prime minister of Nepal:Thaya chaina 3 big rivers: Narayani , Khosi and Bhagmati 3 big city: pokhara , Kathmandu and chitwan Impression: Average

67. Abstract thinking: o Similarity test Q: Apple and Orange A: फलफुल हो , दुबै गोलो हुन्छ । Q: Pencil and pen A: दुवै ले लेखन सकिन्छ । Q: Aeroplane and bus A: दुवै ले मान्छे बोक्छ ।

68. o Proverb test: Q: नाच्न नजान्ने आग्न टेडा A: आफु लाई केहि गर्न आउदिन अनि अरु लाई सिकाउछ। A. कालो अच्छ्यर भैसी बराबर ? B. आफु लाई नआउने कुराहरु बुझ्न गारो हुन्छ । Impression : Intact

69. Judgment: Personal Judgment: was done by asking question i.e घर गया पछि के गर्नु हुन्छ ? She replied “ घर को काम , पड्ने अनि औसधि खाने। ” Social Judgment: behaviour was observed with other’s people in ward, doctor and staff.(well behaved, cooperative and respect them in the ward. Test Judgment: Well stamped envelope test: ठेगाना छ भने खबर गरिदिन छु House on fire Test: आगो निमाउनो सहयोगे गर्छु Facing a snake suddenly test: भाग्छु Impression: Intact

70. INSIGHT: Translated Q: Do you think there is anything the matter with you? A: Yes I have restless and headache. Q: Could it be a nervous condition? A: yes Q: what do you think the cause is? A: mental cause Q: Why do you need to come to hospital? A: To treat my restless and disturbed sleep. Q: Do you think this symptoms were part of a nervous condition ? A: yes Impression: Grade D

71. DIAGNOSTIC FORMULATION: Miss RK, 18 years unmarried Muslim, Studying in class 12 th class , unemployed by occupation, belonging to lower middle socioeconomic status with past history of difficult in seeing near object under treatment for 2 years with family history of suggestive of schizophrenia in father and in elder sister with easy child premorbid temperament was admitted in psychiatric ward with target symptoms of consumption of non nutritive substances that is brick,soil,ash which was persistent and severe enough to require clinical attention with ability to distinguish between edible and non edible substances with exposure to extremely threatening event(physical abuse) at 12 years of age and was re-experienced again and again in the form of memories, repetitive dreams and images with flashback with fear of having episode again with low mood, disturbed sleep, decreased interest in pleasure activites,hopelessness,worthlessness with predisposing factor being positive family history of psychiatric illness in father and elder sister with precipitating factor being physical abuse in children withpersonal history of decline in study due to repeated flash back of events. On MSE revealing-ETEC initiated and maintain with linear and goal directed thought with preoccupied by events with hopelessness,worthlessness , passive death wishes with insight to grade D

72. Provisional diagnosis: ICD-11 : 6B84-PICA 6B40-Post traumatic stress disorder

73. Points favour for PICA Regular consumption of non nutritive substance Persistent or severe to require to clinical attention Based on age and level of intellectual function Points favour for PTSD Exposure to an event Re-experienced in the present Reminder likely to produce re-experiencing of the traumatic event are deliberately avoided. Persistent Disturbed in personal,family,social and education

74. Management: Investigation Sodium 137 Potassium 4.72 Blood Urea 15 Creatinine 0.66 RBS 87 TSH 2.678

75. As the patient was complaint about pain in the head and watering from the eyes the ophthalmic consultation was done.

76. Final diagnosis : Pica with Post traumatic stress disorder

77. MANAGEMENT PLAN: Non pharmacological Pharmacological

78. Non pharmacological Approach Psycho-education to the patients party . Nutritional Counseling Environmental Modification PTSD Checklist for DSM-5 (PCL-5 )=44

79. Pharmacological Approach : Tab fluoxetine 20 mg and dose was increased upto 30 mg per day. Tab olanzapine 5mg per day at night Tab naproxen 250 mg po sos Tab clonazepam 0.25 mg po sos

80. Plan CBT Behavioral Modification Therapy

81. CASE CONCEPTUALIZATION Consumption of non nutritive substance at the age of 2 years Increasing age with ability to distinguish between edible to non edible substance Strong crave for these substance that leads to restless Only relieved crave after eating substance till now 6 years back had physical abuse Reexperiencing of events with images and flashback some time during dreams and during day time Pica and PTSD

82. Topic of presentation

83. Treatments for PICA Various treatments for pica including: Nutritional Psychological Pharmacological Behavioural interventions Ecological Sensory approaches Stiegler , L. N. (2005). Understanding Pica Behavior : A Review for Clinical and Education Professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-38. https://doi.org/10.1177/10883576050200010301

84. Treatment of PTSD Non-pharmacologic treatment for PTSD emphasizes: shared decision-making and collaborative care as vital early interventions The primary recommendation for PTSD treatment is trauma-focused therapy . Research also supports newer therapies, including Cognitive Behavioral Therapy for PTSD , Narrative Exposure Therapy (NET) , and Written Exposure Therapy , which have shown positive effects on PTSD symptoms Pharmacologic treatment for PTSD recommends SSRIs and SNRIs such as fluoxetine , paroxetine , sertraline , and venlafaxine . Schrader C, Ross A. A Review of PTSD and Current Treatment Strategies. Mo Med. 2021 Nov-Dec;118(6):546-551. PMID: 34924624; PMCID: PMC8672952.

85. Reference Stiegler , L. N. (2005). Understanding Pica Behavior : A Review for Clinical and Education Professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-38. https:// doi.org/10.1177/10883576050200010301 Schrader C, Ross A. A Review of PTSD and Current Treatment Strategies. Mo Med. 2021 Nov-Dec;118(6):546-551. PMID: 34924624; PMCID: PMC8672952.

86. THANK YOU