Date post: | 27-May-2015 |
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CASE PRESENTATION
Presenter: Dr. Nilesh BasarkarModerator: Dr. C. Pinto, Dr. J. P. Rawat
Dept. Of PsychiatryJRH BCT.
History• A 19 yrs old Right handed Hindi speaking Unmarried, Hindu male Student of 12th std Resident of Dahisar• Complaints- Self- Headache Sadness of mood
• Objective data- Mother (Adequate & reliable)• H/o – Socially withdrawn behavior Lethargy Loss of interest in surrounding• Total Duration- 6 months.
ODP• Patient was apparently alright 1 yr back.• When he started symptoms without stressor in the form
of Overfriendliness Excess talk Decreased sleep Hyper religious behavior• These symptoms mild in nature & lasted for 6 months.
But they went unnoticed & he was doing well in socio- occupational areas.
• But since last 6 months as the symptoms changed following failure in 12th in the form of
Lethargy Lack of interest in surrounding Socially with drawn behavior• Family members worried & got him to hospital
for psychiatric consultation.
Negative history
• No h/o hearing of voices, muttering to self, laughing alone.
• No h/o suspiciousness, bizarre behavior.• No h/o Repeated hand washing, checking or
cleaning behavior.• No h/o seizure or neurological disorder.• No h/o any substance abuse.
Past & Family history
• No similar complaints in past were noted.• No family h/o Mental illness, Substance abuse,
MR, or Suicide.
Personal History
• Birth history- Full tem normal home delivery• Milestones- Normal• Education- Average in studies Educated up to 11th Failed in 12th • Pre morbid personality- Minimal friends -Poor social involvement -Hobby- watching TV
Physical Examination
• GENERAL EXAMINATION-• Conscious, cooperative & well oriented• General condition fair• Pulse- 72 /min• BP- 130/70 mmHg• RR- 18/min
• NEUROLOGICAL EXAMINATION- Higher functions Sensory system Motor system All examination findings within normal limit.• SYSTEMIC EXAMINATION- CVS, RS, PA findings within normal limits.
Mental Status Examination• General Appearance- Conscious , Cooperative , Kept quite most of the
time during interview. Well dressed• Eye to Eye Contact- Initiated & Maintained• Rapport- Established & Maintained• Attention – Arousable & sustained
• Mood- Sad• Affect- Appropriate• Speech- Continous , Coherent, Relevant Decreased in amount• Thoughts – Ideas of helplessness, hopelessness & worthlessness present. Denies delusions Concept- Simple- Intact
Abstract- Intact
• Perception- No perceptual abnormility present.• Memory- Registration- 3/3 Recall-3/3• Intelligence- General Fund Of Information & Calculation- Both average.• Judgment- Social-Intact Test-Intact• Insight- 3/6 (claims illness as physical disease)
DIFFRENTIAL DIAGNOSIS
• Depressive phase in case of Bipolar Disorder.• Schizoaffective Disorder.
INVESTIGATIONS
• Routine Blood & Urine Examination- Normal• X-Ray Chest-Normal• ECG-Normal• Fundus Exam- Normal• EEG- Normal• MRI Brain- Normal
• PSYCHOMETRIC ASSESSMENT-• BPRS- 24 (mild to moderate psychopathology) • HDRS- 19 (significant depression) • YMRS- 3 (No significant manic symptoms)
DIAGNOSIS
• DSM IV TR- Axis I- Depression in case of Bipolar Mood D/o Axis II- Cluster A personality traits Axis III- No diagnosis Axis IV- Failure in 12th examination Axis V- GAF 61-70 at present & 71-80 before 1
year.
TREATMENT
• Patient was treated on OPD basis.• PHARMACOTHERAPY- Tab. Escitalopram 10 mg (1-0-0) Tab. Na- Valproate 250 mg (1-0-1) Tab. Lorazepam 2 mg (0-0-1)
• PSYCHOTHERAPY-• Individual Psychotherapy- Patient was
explained about nature of illness & importance of compliance.
• Family psycho education- Family members were explained attitude
towards patient & way of dealing with him. • Supportive psychotherapy was also given.
COURSE & TREATMENT RESPONSE
• Patient had depressive features since last 6 months.
• Previous history shows features of hypomania which went unnoticed.
• He was never treated• After starting medication patient improved
40% in 2 weeks.
• He showed 70% improvement after 1 month. • Patient is on regular follow up for medication.
Depression: A global crisis