CASE P PRESENTATIO TION . Dr C Pradyumna PG in Psychiatry A - - PowerPoint PPT Presentation

.

CASE P PRESENTATIO TION

Dr C Pradyumna PG in Psychiatry

 A case of long standing, untreated, chronic schizophrenia

in highly intelligent national chess player from south India.

Name : XXXX Age : 48 years Sex : Male Religion : Hindu Marital status : Separated Residence : Hyderabad Education : B.Sc. Occupation : National chess player Socio-economic status : Lower middle Brought on 5/8/17 to Psychiatric OPD, KIMS Narketpally with his consent by a group of friends (National and International chess players) through PRO of KIMS.

Chief complaints

Subjective complaints -

 No complaints

Objective complaints

 Aimless wandering since 8 years  Aggressiveness since 5 to 6 months  Talking and muttering to self since 5 months  Hearing of voices since 5 months  Suspiciousness since 5 months

BACKGROUND HISTORY

 This case is about one of the most intellectual National

group B chess champion who has been separated from his wife and children since more than 20 years. Both parents died and his 2 brothers never wanted to contact or care for him.

 He continued to stay and wander from one place to

another mostly in temples , mosques & gurudwaras .

 With the support of his friends he would participate in

various tournaments and has been a runner since last 2 years in National chess B champion league.

 Never visited a psychiatrist previously  Poor health and personal care  Erratic sleep and appetite were present

HISTORY OF PRESENT ILLNESS:

 Over a period of last 5 to 6 months his friends observed

that his suspiciousness towards them and whosoever approaches him has increased. He refused to tell them where he resides in the city of Hyderabad unlike to his previous self.

 On closer observation they noticed that he had very poor

• ral hygiene, wearing shabby and untidy clothes without

taking bath for weeks despite on their request and was unnecessarily arguing and talking loudly in threatening attitude to strangers and his chess mates without any apparent reason.

 Further he revealed that he can communicate with God as

he reported that he could hear voice of god.

 He used to touch his ears to the walls of the temple and

would incessantly kiss the idols of various gods and at times he used to touch the feet of few well adored females visiting the temples.

 Their were even few incidences where he was slapped by

security and managerial persons of temples/gurudwaras

 Detailed history about his presentation and other

symptoms were unknown as he was always resented and parried away if any personal questions were asked regarding his family and past.

 However on first of august 2017 , a couple of international

masters in chess group of South Indian federation were informed about his condition and after meeting the acquaintances our patient finally agreed for psychiatric consultation

 However the south Indian chess federation wanted him to

get admitted in some inpatient settings for long term treatment because of inability to stay with him by his friends or family members

 He used to consume alcohol and tobacco whenever he

gets money.

 On night of 2nd august they offered him dinner and wine

but apparently he drank alcohol in a large quantity and became intoxicated

 For couple of days he continued to show :

• Unsteady gait
• Markedly aggressive and violent
• tremulousness and slurred speech

 No h/o low mood /suicidal ideation / over spending  No h/o repeated doing of things /ritualistic activities  No h/o restlessness/palpitation/sweating  No h/o fever  No h/o headache/vomiting/blurring of vision/seizures  No h/o head injury.

GENERAL EXAMINATION

 Patient conscious, oriented.  Asthenic built and ill nourished  Afebrile .  No pallor, icterus, clubbing, cyanosis, lymphadenopathy  Vitals - with in normal limits.

SYSTEMIC EXAMINATION

 Cardiovascular system : S1S2 +, no murmurs  Respiratory system : vesicular breath sounds heard B/L  Gastrointestinal system : NAD  Central nervous system : No focal neurological deficit  Fundoscopy : Normal

MSE ON 5/08/2017

 Untidy ,unkempt ill groomed  Evasive and uncooperative attitude  Shouting , arguing and very agitated  Talking continuously with rambling speech  Contents were at time incoherent and irrelevant  Stereotypic motor movements were present  Threatening gestures towards doctors and friends  Disinhibited behavior present  Increased psycho motor activity is seen  Rapport was established with difficulty  Mood was irritable and incongruent

 Formal thought disorder in form of tangentiality, few

neologisms, poor word associations and circumstantiality were present

 Hallucinatory behavior observed as if talking to no mans

space as if interacting with deities and spirits

 ??Visual hallucinations were present  Delusion of persecution against few people were present  Agreed to play a chess game with consultant of psychiatry

in order to communicate with him.

 His memory was well preserved  Intelligence was good enough in reasoning and high on

calculations

 Concrete level of abstract thinking is present  Social and personal judgements were poor but test

judgement was normal

 No insight about his illness.

DI DIAGN GNOSIS

• CHRONIC LONG STANDING SCHIZOPHRENIA,

PARANOID TYPE

• ALCOHOL INTOXICATION ,

(UNCOMPLICATED,FIRST EPISODE WITHOUT DELIRIUM)

MANAGEMENT ON DAY 1

 Physical investigations like baseline blood investigations  CBP  LFT  RFT  SERUM ELECTROLYTES  PCV  RBS  ECG  CHEST X RAY  USG ABDOMEN were with in normal limits

ACUTE MANAGEMENT:

 Inj Thiamine 100mg iv in 100 ml NS BID  Inj Haloperidol 5mg+Inj Promethazine 25mg im STAT  Inj Diazepam 5mg im STAT

MAINTANANCE :

 Tab Carbamazepine 100mg BID  ENT & Dental referrals  Psychoeducation about the illness to the forum of friends  They insisted for admitting him in drug DTC against his will

without any family support

 Discussed pros & cons and difficulties for his inpatient

hospitalization in KIMS

 Asked them to arrange for regular follow up and was

advised to contact the family members of him if possible.

 Since patient was uncooperative with chronic and long

standing psychosis , And there is no one who could supervise his treatment he was put on a test dose of 12.5mg of long acting Inj Fluphenazine decanoate.

 Base line BPRS score – 76  Planned for further psychometric evaluation

BPRS SCALE:

DAY 14 (19/08/2017)

 Patient was brought by one of his friend  Mild EPS and drooling of saliva ++  Friends tried to contact his family members , his brother

refused to answer back and to take any kind of responsibility .

 Marked reduction in aggressive behavior  Reported decreased frequency in auditory hallucinations  Suspiciousness reduced, muttering to self++  Sleep , appetite and personal care improved  25mg of long acting Inj fluphenazine decanoate was given  25mg of tablet Amitriptyline  2mg of tab Trihexiphenydyl was added.

FOLLOWUP AFTER 1 month (19/9/2017)

 Patient came with general secretary of chess association of

South India

 Oral hygiene improved, 50% reduction in drooling of saliva  Personal care improved  Communication and attitude towards treating team was

markedly changed

 Expressed his gratitude  Avoided talks on his delusions and hallucinations  BPRS score : 41 (about 50-60% improvement)  Wanted to join some job like teaching chess to school

students

 And was further referred to ASHA REHABLITATION CENTER,

HYDERABAD.