Case presentation for 15 th of shawarna.pptm (1).pptx

Psychiatry

1. Case presentation Presenter Dikendra S anjyal Resident Department of psychiatry National medical college teaching hospital

2. AIM : To present the case of a 41 year old female presenting with abnormal behavior, irritability and suspiciousness for diagnostic clarification and further management.

3. Particular’s of patient Mrs. RK Shah, 41 years married Hindu, educated up to class 8, Homemaker by occupation, from Upper middle socioeconomic status, belongs to nuclear family, residing from Bara, was admitted on 9 th June 2024 and was examined on 9 th June 2024. Source of referral: Family members

4. Source of information: Patient herself Family members: Husband: Mr.BP , 50year, Studied upto class 8, Electrician by occupation has been staying with patients and known about her illness. Information provided is reliable and adequate

5. Chief complant’s According to the patient: Kehi vayako xaina ………… According to the informant: Abnormal behavior…………………………for 16 year Irritability……………………………………for 16 year Suspiciousness……………………………….for 16 year

6. Total Duration of Illness: 16 Years ONSET: Insidious COURSE: Continuous PRECIPITATING FACTOR: Death of her first husband PREDISPOSING FACTOR: not known PERPETUATING FACTOR: Non-compliance to medicine

7. HISTORY OF PRESENT ILLNESS According to the informant she was apparently well 16 years back. After death of her 1 st husband then family members decided her second marriage. After marriage the patients was well till the symptoms developed. Than few days later the patient suddenly started allegedly beat everyone in the family members and became irritable and anger towards them, if someone tried to ask her about the reason. Most of time the patient abused both physically and verbally towards family members. In anger the patient would speak in loud voice and didn’t calm down for while. This irritable only occurred if someone of family members provoked her most of time but sometime would occur without provocation.

8. The informant didn't t bother her as he thought it was the part of her stressor as he know about her stressor. The patient would walk here and there in the house and didn’t sit for while ,and would say “ the present husband was not loyal, he didn’t take care of him and didn’t give money for house chore activity as he would earn lots of money as electrician. He and other family members and tried to kill her by mixing food with poison and without give money for her food. On further asking to the patients she continuously replied above one and didn’t eat food give by the family members and her husband. If some one forced her to eat she would ask them to eat first and after sometime the patients had her food.

9. The patient would speak in loud voice by saying all family members made plan to kill her but it was not possible because the paitent used to observe them without knowing by them. One day all her family members was present during festival and there were gossping to each other and she was doing work in the kitchen.After sometime the patient came immediaterly and started to abuse them by saying “you people have no work and only spend time by saying negative things to me. She would do occasionally when family members or neighours were speaking to each other.

10. In irritable the patient would remove clothes and turn them and sometime she would throw things here and there in the room. This kind of behavior was continuously and had diificult to control her by family members. The patient didn’t sleep at nght.she would continoulsy said her husband didn’t love her and made plan to kill her at night. The patient would think if I slept than her husband killed her easily during sleep. So the patient had restless and would roll and toss frequently in bed and after sometime she would wealk in the house.

11. This symptoms for 1 year, family members took her India for treatment and was under medication. As the document was not available but the informant said the size of medicine and small and after having that she would sleep well and her appetite was increased than before. She continuously took the medicine for 1.5 years and was improved 80% according to the informant. Her sleep and appetite was improved and used to function well. But her suspicious toward her husband and family members not improved. She would tell frequently ‘her husband made plan to kill her by involving other family members. When ever she was taking medicine the intensity was dcreased . The patient would only eat food made by herself and given by her elder daughter.

12. She would had frequent altercation with her husband whenever he tried to console her. This symptoms was continuous and was gradually increased in nature for till now. 6 month back before the admission, the patient didn’t sleep at night, she would start to speak in loud voice at night. She would say irrelevant things such as “ my husband didn’t love me, he didn’t give money as he earned than 50000 Npr per month and aslo said he was not failthful to her. The patient would abusely beat her husband and didn’t eat anything given by him. The patient would sleep at 1-2 AM at night and awoke up at 6 :00 Am in the morning.

13. She slept for 2 to 3 hours at day time. After that she didn’t interact with family members and spend time alone by lying in the bed in day time. Previously the patient would finish all housechores activity by alone. Without doing work, nowdays the patient became tired. She felt weakness all over day and night. With this symptoms her husband took her in private hospital and was prescribed Tab Olanzapine 5 mg twice daily, Tab Sertraline 25 mg once a day.she took the medicine for 10 days and left the medicine. She would start to do housechore activity but her suspicious was never improved till now. As the patient had difficult to control as she started to abuse verbally in loud voice and would allegedly beat every one in the family members.

14. As the informant would say her abnormal behavior would occur suddenly for some time and after treatment or without treatment she would become normal but suspicious never improved and brought her forcefully by family members for admission in NMCTH ER and got admitted.

15. NEGATIVE HISTORY No h/s/o Head injury or fever with vomiting and headache with focal neurological deficit s/o CNS infection Any substance abuse Increased self-esteem with increased psychomotor activity and elated mood with grandiose content Feelings of nihilism, hopelessness, persistent or pervasive with low mood Anticipatory anxiety or fear to any living or non-living things, place or animal Repetitive, intrusive, involuntary thoughts associated with compulsive acts 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.

16. TREATMENT HISTORY Mention in HOPI

17. Past History: No past history of psychiatry/medical/surgical illness. No past history of allergy and drug reaction

18. FAMILY HISTORY Genogram:

19. Patient’s belonged to nuclear, Upper middle socioeconomic status of hindu . Her family consisted of father, mother and 5 children including her. Siblings Eldest brother: 44 year old, married, runs local business of vegetables, has distant relationship with patient and doesn’t know about her illness, lives in hetuda . Younger brother: 39 yr old, married educated upto primary level farmer by occupation,live in birgunj , has not in contact with patient and know about her illness.

20. Youngest sister : 37 year old, married, house-wife, lives in Birgunj . Patient has good relationship with her sister and in touch. Supportive during illness. Youngest sister : 35 year old, married, house-wife, lives in Birgunj . Patient has good relationship with her sister and in touch. Supportive during illness Patients father: 68 year old, married, no formal education, live in bara, has good relationship with patient , head of family,primary bread winner and primary decision maker of the family, has no history of psychiatry/medical and surgical illness. Patient mother: 66 year old,married , no formal education, live in bara, has good relationship with patients, primary care giver of family, has no psychiatry,medical and surgical illness. IPR among family members-good and IPR between family members and patient -good

21. Patient after marriage also lived as nuclear family with her husband and 1 sons Patient husband died 16 year back due to some medical condition She did second marriage after death of 1 st husband Head of family- patients current husband Primary care giver – patients herself Primary breadwinner- patients husband IPR between patient and family members- disturbed after illness IPR among the family members –Good Family members support her fully both emotionally and financially No history of continuous stressor in the family No history of psychiatry/medical/surgical illness

22. PRESENT LIVING SITUATION Own pucca house No overcrowding financial constraints present

23. PERSONAL HISTORY Birth history and developmental history: couldn’t elicited Childhood and adolescent history:

24. Educational history: Started school at the age of 5 years. Was average student, never had to repeat any class and used to pass every exams. Regular attendance No history of bunk from school and conflict with teacher. Studied up to grade 8 and had to left education after marriage. Interpersonal relation with friends used to be good.

25. Occupational history: House maker. Sexual history: Identifies as female at the age of 4 and is attracted to males, had no relationship before marriage. No specific fantasies were told by the patient.

26. Menstrual history: Age of menarche: 12 year Menstrual cycle/ menstrual period: 4day/28 day But for 4 years – injectable contraception was used (Copper-T) and amenorrhea for 4 years

27. Marital History: Married for 22 years . Arranged marriage with consent. Has 1 children 1 st husband died due to some medical condition within 2 years of marriage. Got 2 nd marriage with consent from family members Had 2 son from 2 nd marriage Interpersonal relation with husband is disturbed after illness. Other history could not be elicited .

28. Drugs and Substance: No history of any substance taking behaviour.

29. PREMORBID PERSONALITY: Social relation: Helpful, likes going out, extrovert. Intellectual activities, hobbies: Participated in social gathering, takes responsibilities and have fun with friends. Her hobbies are reading. Mood: Mostly euthymic, but fluctuations of emotions present. Attitude to self: she became irritable if demanded things are not available for some time and she became normal, self confidence.

30. Attitude to work and responsibility: Welcomed responsibility, helpful to colleagues. Attitude to religion: Beliefs on God but not overtly religious. Energy: Average Fantasy: No specific fantasies. Habits: Regular Impression: Well Adjusted

31. General Examination : GCS : E4 V5 M6 Weight : 53 kg Height : 5ft 3inch(163 cm) BMI : 19.9 kg/m2 Vitals : Temperature : 98.6 F PR : 82/min RR : 14/min Spo2 : 99% in RA BP : 110/90mm Hg No Pallor/ Icterus/ Lymphadenopathy/ Cyanosis/ Clubbing/ Dehydration

32. Systemic Examination : Cardiovascular: S1, S2 heard, regular No murmur heard Respiratory: Air entry equal on both sides, no added sounds Per abdomen Soft, non tender, no hepato -splenomegaly or abnormal palpable mass Bowel sounds heard

33. 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

34. 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

35. Oculomotor, Trochlear, Abducens Eyeball central in position, gaze intact in all directions Trigeminal: Muscles of mastication: intact Sensation over face: intact Corneal reflex: intact

36. 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

37. Motor System: Muscle bulk: B/L equal Involuntary movements: not present Muscle tone: Not increased or decreased Muscle power: 5/5 over all limbs

38. Sensory: Light touch: Intact B/L equal Pain: Intact Temperature: Intact Vibration: Intact Joint position and movements: Intact

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

40. 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

41. Cortical signs: Tactile localization: normal Two-point discrimination: normal Stereognosis : normal Graphesthesia : normal

42. Meningeal Signs: Neck rigidity: not present Kerning’s Sign: not present Brudzinski Sign: not present Impression: No neurological deficits were noted

43. MENTAL STATUS EXAMINATION GENERAL APPEARANCE AND BEHAVIOUR Build: an obese built female Age: appropriate as stated Clothing: Wearing a green Sari, appropriately dressed according to sex, climate and culture Hygiene and grooming: adequate and maintained Gait: No abnormalities noted Gestures: normal Facial expressions: Anxious facial expressions

44. Abnormal movements: absent Greeting: returned by saying Namaste Eye contact: initiated and maintained Attitude: cooperative Psychomotor activities: patient would become irritable to her husband and abuse him verbally and didn’t sit for while during ward that indicated Increased PMA. No catatonic and hallucinatory behavior noted Rapport: was established

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

46. Mood/Affect: S = Q: तपाई को मन कस्तो छ? A: राम्रो छ। O = o Quality: Euthymic to irritable o Range: Broad o Fluctuation: not present o Reactivity: present o Congruent to Thought: present

47. Q.तपाई आफ्नो घर को बारेमा केहि भनु होस् ? A.मेरो घर बारा जिल्ला कनैया मा पर्छ । घर मा श्रीमान छोरा हरु छन् । अरु केहि छैन । Q.तपाई आफ्नो मन पर्ने चाडपर्ब को बारेमा भनु होस् ? A.मलाई दीपाओली,छठ पुजा मनपर्छ । अनि मिठो मिठो खान पाइन्छ । 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

48. 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: लाग्छ , मेरो कुरा गर्छन।

49. Q. हजुर को कुरा कसले गर्छन जस्तो लाग्छ ? A. मेरो घर को मान्छे ले मेरो श्रीमान अनि नन्द हरु ले। Q. के कुरा गर्छन ? A. मलाई नराम्रो छ र मेरो बारेमा कुरा काटछन्। Q. अनि हजुर लै कसरि थाहा भायो कि तिनी हरु ले तपाई को कुरा गर्छन ? A. अनि म नजिक जादा तिनीहरु चुप लाग्छन र मैले गाली गर्छु त्यसपछि केहि बोल्दैन। Q. के तपाईलाई कसैले हानि नोक्सानी पुराउन या मार्न चाहानछन् जस्तो लाग्छ ? A. मलाई मेरो बूढा र नन्द ले मार्न खोज्दै छन। Q. अनि तपाइँ लाई किन मार्न खोच्दै छन् ? A. म नारार्म्रो छु , अनि मलाई मारे पछि मेरो श्रीमान ले अर्को बिहे गर्छन। Q. तपाई लाई कसरि थाहा भयो ? A. तपाई लाई थाहा छैन मेरो बुडा संग धेरै पैसा छ अनि त्यो मलाई नदिन खोज्दै छ अरो धेरै कुरा नासोध्नो।

50. Q: के तपाई लाई लाग्छ जादू टूना गरेर तपाई लाई बस मा गरेको जस्तो लाग्छ । A: लाग्दैन। Q: कैले काई हजुर लाई जीवन बेकार छ , बाचेर के गर्नु लाग्छ ? A : छैन तेस्तो केई। Content: delusion of persecution & delusion of reference + no hopelessness, worthlessness

51. 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

52. 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: लाग्दैिन । Impression: No hallucination and derealisation.

53. Cognition : Orientation : Time: Period of day: Afternoon Estimated time: 2 pm Day: Tuesday Date : 15 th -02-2081 Season: Summer Place: Country : Nepal City: Birgunj Place: National medical college Floor : first Ward : Psychiatry Person: Identity of accompanying informant asked, identified as Dewar with correct name Impression : Oriented to time, place and person.

54. Attention: o Digit forward: 4 DF o Digit Backward: 3 DB Concentration: o Serial subtraction : Could not do 100-7,40-3 and able to do20-1 with no mistake and took 1 minutes . 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

55. 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 marriage : correctly confirmed Year of birth of first child: correctly confirmed Impression: Preserved

56. 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 xaina 3 big rivers: Narayani , Khosi and Bhagmati 3 big city: Pokhara , Kathmandu and chitwan Impression: Average

57. 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 ।

58. 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

59. Judgment: Personal Judgment: was done by asking question i.e घर गया पछि के गर्नु हुन्छ ? She replied “ घर को काम गर्ने 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 but became irritable toward husband 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: बाटो फेर्छु Impression: Intact

60. INSIGHT: Translated Q: Do you think there is anything the matter with you? A: No Q: Could it be a nervous condition? A: I don’t know Q: what do you think the cause is? A: I don’t know . I am ok Q: Why do you need to come to hospital? A: brought forcefully against my will Impression: Grade A

61. DIAGNOSTIC FORMULATION: Mrs RK Shah, 41 years married Hindu, educated up to 8th class, homemaker by occupation, belonging to upper middle socioeconomic status presenting in NMCTH with target symptoms of delusion of persecution,delusion of reference, disturbed sleep for 16 years with TDI of 16 years, insidious onset,continuous course with treatment history of Tab olanzapine 5mg BD and Tab Sertaline 25mh OD with poor drug compliance with no family history of psychiatry illness with well adjusted premorbid personality . MSE revealing anxious facial expression eye to eye contact – initiated but not maintained with Increased PMA with Increased Tone/Pitch and Volume with euthymic to irritable affect with delusion of persecution and reference with grade A insight.

62. Provisional diagnosis: ICD-11 : Delusional disorder( 6A24)

63. Favor point Presence of delusion, typically persisting for at least 3 month and often much longer,in the absence of depressive, manic or mixed episode Delusions are variable in content showing remarkable stability Absence of clear and persistent hallucinations Related to delusion system ,affect and behavior Symptoms are not a manifestation of another medical condition

64. Management: Investigation:

65. ECG was done which came in normal limits. Final diagnosis: Delusional disorder, currently symptomatic

66. MANAGEMENT PLAN: Non pharmacological Pharmacological

67. Non pharmacological Approach Psychoeducation to the patients party regarding her illness. BPRS was used and came high score in S USPICIOUSNESS

68. Pharmacological Approach: Patient was started with Tab Olanzapine 5mg slowly the dose was increased and now she is taking 15mg/day Tab Lorazepam 1 mg TDS was started which has been tapered 1 mg BD as patient sleep was not disturbed.

69. Plan in follow up BMI Blood glucose levels ECG Lipid profile

70. CASE CONCEPTUALIZATION After the death of her first husband being precipitating factor Sudden onset of delusion of reference and delusion of persecution Affect and behavior of the patient Under medication but poor drug compliance to medicine being perpetuating factor Delusion for persecution and reference for long period of time without hallucination Delusion disorder