CL RoundsOctober 14, 2009

General Data•SL•28/M•RH•Married•unemployed•Union Espiritu•Kalinga, Apayao•Admitted Aug 22, 2009 for the first time

in PGH•Informant: patient and wife-good

reliability

Chief complaint:

•Psychiatric complaint: Depression•Orthopedic complaint: B LE weakness

History of Present Illness:

•1 Yr PTA Numbness at bilateral feet with mild

weakness which progressed with sensory loss (-)trauma/fever. Patient was ambulatory but

claimed to have limping gait. There was bowel and bladder incontinence, No consult at this time and no medical intervention.

started to manifest with depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia.

•11 mos PTA:▫Weakness of both feet ascended to both

legs without sensory loss. At this time, the patient had no urine output for 2 days. He then consulted at a local hospital. Folley Catheter was inserted and was sent home. There was no associated fever, hematuria, dysuria.

▫He consulted with a private physician and was given with the Impression SCC. CT Scan was not done due to lack of funds. At this time, the patient was still ambulatory but needed moderate-maximal assist.

• Aug 2009▫consulted at PGH. MRI was done which showed

spinal and epidural soft tissue mass, causing spinal cord stenosis and cord compression patient was then advised surgery hence admission

▫depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia, decreased in intensity after starting treatment in PGH.

▫Patient again started having said symptoms with anhedonia and thoughts of death after he was informed of difficulty securing donors and funds for his operation.

▫Patient is still somehow hoping though that he will be able to walk again, as what his attending physician informed him.

Review of Systems:• (-) fever• (-) headache• (+) weight loss• (+) anorexia• (-)DOB• (-)chest pains• (+) incontinent bowel and

bladder• (+)sweats

Past Medical History

•malaria at 10 y/o•PTB (2006)- incomplete treatment•Hospitalization (2006) secondary to PTB x

10 days•(-) DM/HPN/Heart Dse/Allergy/BA/liver

and kidney dse

Family Medical History

•(+) Cardiac, pulmonary dse•Wife has ANM undiagnosed x 8 yrs•(-) DM/HPN/Heart Dse/Allergy/BA/liver

and kidney dse•(-) same condition

Personal Social History

•Currently a non smoker and non alcoholic beverage drinker, denies illicit drug use

•Patient is currently unemployed•He previously worked as a farmer•His regular diet includes mainly vegetable

and raw fruits•He lives with his wife, 3 children, father

and sister-in-law in a 1 story house with wooden flooring in a studio type nipa hut

Functional History

•Premorbidly independent in all ADLs like grooming

•Min-mod assist in bed mobility and transfers from wheelchair to bed

•Good sitting balance and tolerance•Needs max assist and support from a

stable furniture•Incontinent bowel and bladder

Anamnesis

•Patient is the eldest among 5 living siblings. He was breastfed and had his proper toilet training at age 3.

•As a child, he was active and friendly. He plays with the children around the neighbourhood. And he gets along with his siblings well. He was sickly as a child. But this did not prevent him from making friends or caused any withdrawal from playing and making friends.

•The patient did not go to school and did not have any formal education. As said by his wife, he can’t read or write.

•At 19, he got married. Present has 3 children being 9, 6 and 4 year old. The eldest is being sent to school.

•The patient and his wife are both farmers. They have no problem with the simple life that they have until this present condition where it threatens to tear down the simple happy life that they are most contented with.

• At present, numbness is felt from feet up to waist down. The patient cannot walk and stand without the aid of help. He keeps himself in bed. And occasionally becomes uncooperative. The operation he needs cannot be scheduled without any blood and funds.

• The patient expresses his wish to go home.• Because of the almost 3 months stay in the

ward, resources with time are depleting. This mainly includes food for the bantay, pamasahe going back to the province to seek help and also visit the children and family.

• The patient has no relatives in Manila. So his wife and father stay with him at the wards.

Physical Examination• General Survey: Conscious coherent, oriented

to three spheres and NICRD• BP:110/70 HR: 71 RR:20 afebrile• HEENT

▫PC, AS, (-) TPC, (+) CLAD, (+) anterior neck mass, soft, nodular, non tender moves with deglutition, (-) bruit

• CHEST AND LUNGS▫ECE, CBS, (-)crackles/wheezes

• CVS▫AP, DHS, (-)murmurs

• ABDOMENFlat, NABS, (-) bruit, nontender

Neurologic Examination

•alert, coherent, oriented, NICRD•CN intact

•Motor▫normotonic, fair sitting balance and

tolerance, B UE active and passively done, B LE passively done

▫UE: 5/5▫LE: 3/5

•Sensory▫C2-T6: nosensory impairment to pain and light

touch▫T1-S3: impaired sensation to pan and light

touch

•DTRs▫++ B UE▫+++ B LE

• (+) Babinski• (+) Sustained clonus• (-) Nuchal rigidity

Mental Status Exam•The patient is alert, oriented to three spheres

and cooperative.•The patient is cooperative and attentive,

dressed appropriately according to age and gender, calm with fair eye contact. He showed no odd behaviours. He was smiling most of the time and speaks spontaneously with normoproductive speech and soft voice. He has a broad affect and euthymic. His thoughts were productive and goal oriented.

•He has no memory impairment remote, recent, and past.

•He admits that at the moment, he has thoughts of dying. He has no idea on a specific manner of ending his life, but just the thought and idea of death. He sees death as the only way that would end his sufferings and his family as well. He sees himself as useless and only gives constant problems to his family. He says to himself in his thoughts, if I were dead, maybe I can be of more use because I am not a burden anymore.

• Intact cognition, fair insight, impulse control and judgement

•He has no persecutory delusions, hallucinations.

Assessment

Diagnosis • Axis I: Mood disorder secondary to a general

medical condition vs MDD• Axis II: None• Axis III: Spinal cord injury, incomplete ASIA D, level

T4, prob secondary to potts disease vs metastasis from a thyroid primary

• Axis IV: financial constraint, medical illness, inability to work

• AXIS V: GAF: 61 – 70 (some mild symptoms [depressed mood or mild insomnia] or

some difficulty in social, occupational fnc

Differential diagnosis – AXIS I• Mood

disorder secondary to GMC

• Major depressive disorder

• Adjustment disorder with depressive symptoms

Diagnostic criteria• Prominent and persistent disturbance in

mood characterized by either or both1. Depressed mood or diminished

pleasure or interest2. Elevated, expansive, irritable mood

• Direct physiological consequence of a GMC

• Not accounted by another mental disorder

• Not during a delirium• Sx cause significant impairment in

function

Differential diagnosis – AXIS I• Mood

disorder secondary to GMC

• Major depressive disorder

• Adjustment disorder with depressive symptoms

• Major depressive episode (5 or more)• Depressed mood for most of the day• Diminished interest or pleasure• Significant weight loss• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue or low energy• Feelings of worthlessness

inappropriate guilt• Decreased concentration, ability to

think and indecisiveness• Recurrent thoughts of death

Differential diagnosis – AXIS I• Mood disorder

secondary to GMC

• Major depressive disorder

• Adjustment disorder with depressive symptoms

• Not a mixed episode• Causes significant distress and

impairment in social , occupational and other important functions

• Not a direct physiological effect of a substance or a general medical condition

• Symptoms are not because of bereavement

Differential diagnosis – AXIS I• Mood

disorder secondary to GMC

• Major depressive disorder

• Adjustment disorder with depressive symptoms

• Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within the 3 months of the onset of the stressors

• Symptoms or behaviors are clinically significant as evidenced by ▫ marked distress that is in excess of what

would be expected from the exposure to the stressor

▫ Significant impairment in social or occupational functioning

• Stress related disturbance does not meet the criteria for another axis I or II disorder

• Symptoms not because of bereavement• Symptoms resolve within 6 months

Bereavement

•May present similar to depression•Usually doesn’t involve prolonged feeling

of:WorthlessnessGuiltSelf reproachThoughts of death

Biopsychosocial FormationBiological Factors

Psychological Factors (internal in the patient)

Social Factors (external/ outside world)

Predisposing Factors

Pulmonary TB (2006)

Poor self-esteemLow educational attainmentlack of awareness regarding need for consult

Poor health care system in the area

Precipitating Factors

Spinal Cord Compression

Feeling of worthlessness

Lack of funds

Perpetuating Factors

Progressive weakness, sensory deficit(-) resolution of symptoms

Continued unproductivityThoughts of hopelessness of the condition

Continued delay in surgeryDepletion of resources ( food, fare)

Treatment Goals

•Ensure patient’s safety•Address immediate symptoms and

prospective problems

Treatment Plans

▫Cognitive therapy (expressive – empathic) Address ego regression (damaged self-esteem

and unresolved conflict due to childhood loss or disappointment)

Promote personality change through understanding of past conflicts

Achieve insight to defenses, ego distortions, and superego defects

Provide a role model Permit cathartic release of aggression

Psychosocial Therapy

▫Interpersonal therapy (behavioral – cognitive) Address distorted thinking (dysphoria due to

learned negative views of self, others and the world)

Provide symptomatic relief through alteration of target thoughts

Identify self-destructive cognitions Modify specific erroneous assumptions Promote self-control over thinking patterns

▫Behavior therapy (communicative – environmental) Address impaired interpersonal relationships

(absent or unsatisfactory significant social bonds)

Provide symptomatic relief through solution of current interpersonal problems

Reduce stress involving family or work Improve interpersonal communication skills

▫Family therapy Examine the role of the mood-disordered

member in the overall psychological well-being of the whole family. And the role of the entire family in the maintenance of symptoms.

Pharmacotherapy

▫Patient education regarding the possible side effects of medications and the need for compliance and other drug-drug and drug-food interactions

▫Selective Serotonin Reuptake Inhibitors Effective, easy to use, relative lack of adverse

effects Examples: fluoxetine, paroxetine, sertraline,

venlafaxine, bupropion, etc.

▫Tricyclic Antidepressants Lethal when taken in overdose, cardiotoxic, causes

hypotension, decreased libido, erectile dysfunction, anorgasmia

Examples: amitriptyline, desipramine, imipramine, nortriptyline

▫Monoamine Oxidase Inhibitors Causes serotonin syndrome (hyperthermia, muscle

rigidity and altered mental status) when taken with SSRIs, meperidine and pseudoephedrine, also causes hypertensive crisis when ingested with foods rich in tyramine

Examples: phelzine, tranycypromne

Electroconvulsive therapy:

•used when the patient is unresponsive to pharmacotherapy or cannot tolerate pharmacotherapy or clinical situation is to severe that the rapid improvement seed with ECT is needed

Phototherapy•for those with seasonal mood disorder

Treatment Duration

•When in full remission, maintain treatment for at least 4-6 months in case of first-time episode but longer in recurrent disease

Thank You!

Biological Factors

Psychological Factors (internal in the patient)

Social Factors (external/ outside world)

Predisposing Factors

Pulmonary TB (2006)

Poor self-esteem

Poor health system in the area

Precipitating Factors

Spinal Cord Compression

Feeling of worthlessness

Lack of funds

Perpetuating Factors

Unable to have an operation

Unproductivity Depletion of resources ( food, fare)