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J.N is a 37-year-old farmer who was admitted to the hospital after chasing people with a panga. He has a history of 4 psychiatric admissions dating back to 2005 for episodes of hearing voices and seeing things. His most recent episode included thoughts of suicide and homicide. On examination, he displayed no abnormal mental status findings and was oriented with good cognition. He meets criteria for a diagnosis of schizophrenia.
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0% found this document useful (0 votes)
32 views37 pages

Group 3 Presentation.

J.N is a 37-year-old farmer who was admitted to the hospital after chasing people with a panga. He has a history of 4 psychiatric admissions dating back to 2005 for episodes of hearing voices and seeing things. His most recent episode included thoughts of suicide and homicide. On examination, he displayed no abnormal mental status findings and was oriented with good cognition. He meets criteria for a diagnosis of schizophrenia.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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PSYCHIATRY CASE

PRESENTATION

VICTORIA MAPENZI
CYNTHIA MONTHE
FAITH WANJIRU
Biodata.
Name: J.N.
Age: 37 years.
Sex: Male.
Residence: Ngong.
Occupation: Farmer.
Religion: Christian.
Level of education: Secondary.
Marital status: Separated.
Source of referral: Police.
Cause of referral: Chasing people with a panga.
Mode of admission: Emergency.
Date of admission: 23/01/2023.
Place of interview: Ward 8M, Mathari national teaching and referral hospital.
Time of interview: 10AM.
Language of interview: Kiswahili and English.
Informant: Patient.
Allegations

 Hearing voices other people could not hear- on the day of admission

 Seeing people other people could not see-on the day of admission

 Thoughts of killing himself-on the day of admission

 Chasing people with a panga-on the day of admission


History of presenting illness.
The patient was relatively well until on the day of admission when he started hearing voices
that other people could not hear and seeing people that other people could not see, and these
people and voices were unfamiliar to him. These were occurring concurrently. The voices
from the people were mocking him about how stagnant his life is being 37 years, still living
with his mother, not providing for his son and how his wife left him following incitement
from neighbors about her being patient with someone that is mad. He reports that he was
seeing the people who were mocking him but he could not recognize them.
These voices proceeded to tell him that the only solution that he had was taking his own
life. He thought that the most lethal way was to use the rat rat poison, so he went and
bought it, then wrote a suicidal note addressed to his mother, telling her how he thinks he is
a burden to her. However, as he was about to drink it, the voices abruptly told him to kill
other people instead. The thought of killing himself was impulsive and purely from the
voices and has never had any other similar thoughts.
Immediately he took a panga and ran towards the market center, chasing people, wanting to
kill them. He was then restrained from behind by a group of people who took him to the
police station, but he does not remember for how long he was in custody. Later he was
brought to mathari national teaching and referral hospital. He reports that he has spent a
month without taking his medication because he was tired of taking them. He denies being
under the influence of any substances during this episode.
Psychiatry review of symptoms
• He reports that during this episode he was easily angered even at people greeting him.
• He reports that he used to sleep from 9pm to 6am before, but during this episode he slept
for 3 hours and woke up feeling well rested.(3am-6am)
• He was feeling like a billionaire and could go to the bazaar, order a car and say that he
could go back the next day.
• He reports that whenever his mother gave him money, he would give it out to people he
knew or even strangers.
• He reports that during this episode he was talking a lot as this was noted by his mother.
• He had no change in appetite and libido
• No loss of interest in watching football
Medical review of systems
• CNS - no headache, no dizziness

• CVS - no palpitations, no easy fatigability

• RS - no cough, no chest pain, no difficulty in breathing

• GIT - no nausea and vomiting, no abdominal pain, no change in bowel habits

• GUT - no dysuria, no increased urgency or frequeny, no hematuria

• MSS - no joint or muscle pains


Past psychiatric history
This is the 4th episode, 4th admission
1st episode was in 2005, due to hearing voices other people could not hear and seeing things
other people could not see, violence towards people, he was admitted for 1 month, he was
treated and was discharged on olanzapine and tegretol. He reports non compliance because
he believed that he was okay.
2nd admission was in 2019, 3rd admission in 2020. he presented with the same symptoms,
was admitted for a month and discharged on olanzapine and tegretol. He reports non
compliance because he still believed he was okay.
He was also on modecate 1 injection monthly but reports non compliance too.
Past medical history
No history of admissions

No known chronic illness

No known food or drug allergies

No history of blood transfusion

No history of surgery
Family history
He is the second born in a family of 2 siblings
Father- T.W, died in 2010 due to a road traffic accident. The patient was 24 years old at the
time. He reports it made him sad for some time but he got over it. Had no history of mental
illness, no history of substance use, no history of chronic illness. Had a good relationship
with the patient.
Mother-W.K, 80 years old, a farmer. Has no history of mental illness or substance use. No
history of chronic illness. Has a good relationship with the patient.
1st born- S.G, male, 53 years old, lives in dubai. No history of mental illness. No history of
chronic illness. Has a good relationship with the patient.
There is a family history of mental illness in the extended family. His uncle from the
maternal side presented at 30 years with seeing things that other people could not see and he
was admitted at mathari national teaching and referral hospital.
Personal history
Birth history
He was born in 1986 via svd. Perinatal events are unknown to him. He had good
developmental milestones and received all vaccinations.
School
He started primary school at 4 years of age, at Ngong primary school and studied from class
1-8. scored 340/500 in KCPE. Best subject was English. He had no history of truancy. Had
a good relationship with teachers and students. He had no leadership roles.
He joined Nakuru high school at the age of 15 years. He studied from form 1-4. He scored a
C plain in KCSE. No history of truancy, no leadership roles. Had a good relationship with
teachers and students. Best subject was English and agriculture.
He did not join any college due to financial constraints. This did not affect him in any way.
Occupation history
After completing high school, he started helping his mother in the farm and since he has
been working there.
Relationship history
He has been in 6 relationships. They ended due to infidelity on his side. Except for on that
led to marriage.
Marital history
He separated with his wife 1 year ago, they had a son together.
Son- W.K. 7 years old. He does not know his son is doing since the separation. Not
knowing about the wellness of his son affects him.
Sexual history
Sexual debut was at 18 years with a 18 year old female. It was consensual.
He has had 6 sexual partners and he occasionally used protection
He has no history of STIs
No history of masturbation.
Drug and substance history
he denies the use of any drug or substances
Forensic history
No history of arrests
No history of convictions
No history of court arraigns
Premorbid personality

His friends describe him as friendly, caring and hardworking

His hobbies are watching football and this has not changed.

Current living conditions

He lives in a 2 bed room house with his mother

Uses gas as a source of fuel, electricity for lighting and tap water for drinking and cooking.
Physical Examination.
General examination
• Found a man in a fair general condition, not in respiratory distress and was clinically
afebrile.
• He had no conjunctival parlor, no scleral jaundice, no central cyanosis, no edema, no
lymphadenopathy, no finger clubbing, not wasted and not dehydrated.
• Vital signs:
• BP- 109/76 mmHg
• HR- 91bpm
• RR- 16 bpm
• Temperature – 36.8 0C
• All were normal.
Systemic Exam.
Central nervous system:

• GCS- 15/15, Alert, well oriented to time, place and person and person.

• Cranial nerves were intact.

• Coordination was normal.

• Sensory – fine touch, crude touch, temperature and pain sensation were normal in all
dermatological areas tested.
Cardiovascular system:

• No palmar pallor, capillary refill in 1 second, pulse rate 91 beats/minute, no distended


neck veins.

• Precordium: on inspection – normo active; on palpation – apex beat at 5th ICS-MCL, no


heaves, no thrills; on auscultation – S1, S2 heard, no murmurs, no added heart sounds.
Respiratory examination:

• Inspection: not in respiratory distress, respiratory rate of 16 breaths/minute, no scars, no


obvious swelling.

• Palpation: centrally located trachea, symmetrical chest wall expansion, no tenderness.

• Percussion: normal resonance bilaterally, anterior and posterior.

• Auscultation: bilateral vesicular breath sounds over the lung field both anteriorly and
posteriorly.
Per abdomen:

• Inspection: moves with respiration, neither distended nor scaphoid, no scars, umbilicus
was inverted.

• Palpation: no tenderness on both light and deep palpation, no organomegaly, liver span of
10cm.

• Percussion: tympanic.

• Auscultation: normal bowel sounds.


Mental State Examination.
Appearance and behavior.

• We met a man who was kempt, in hospital attire. He was of a short stature and brown
complexion. He had no mannerisms or stereotypies. Rapport was easily established and
he maintained eye contact throughout the interview.

• Speech: normal tone, volume, rate.

• Mood: was euthymic and affect was mood congruent.

• Perception disturbances: no illusions, hallucinations, depersonalization or derealization


• Thought:
• Form: no flight of ideas, tangentiality, loosening of associations.
• Content : no delusions, obsessions, overvalued ideas, suicidal ideation.
• Control : no thought insertion, withdrawal or broadcasting.
• Cognitive:
• GCS 15\15, alert, well oriented in time, place and person.
• Attention – good.
• Concentration – good.
• Memory:
• Registration – good.
• Immediate – good.
• Short term memory- good.
• Long term memory- good.
• Abstract thinking- good.
• Judgement- good.
• Insight level- IV (He is aware he was sick, but does not know the cause of his illness).
Diagnostic formulation.
• J.N, 37-year-old, separated for one year, with a secondary level of education, had an
emergency admission 2 weeks ago and presented with allegations of bizarre behavior,
unsuccessful suicidal attempt, visual and 2nd person commanding and general auditory
hallucinations on the day of admission; pointing a psychotic disorder.

• Complementary to this presentation, he had irritability, decreased need for sleep,


grandiose delusions, impulsivity and talkativeness, indicating a concurrent mood disorder.
He also had a sad persons scale of 8/14 which warrants a full emergency psychiatric
evaluation and treatment.
• However, he denies any history of substance use even for this episode. This is the 4th
episode and 4th admission, with a history of non-compliance to olanzapine and
carbamazepine and would benefit from psychoeducation and depot medication. A family
history of mental illness could be his predisposing factor while his illness could be
perpetuated by his noncompliance to medication. Separation with his wife, not knowing
the wellness of his son in addition to non-compliance could have precipitated this
episode. Patient seems to have no protective factor.
• His two-week duration as an inpatient while the symptoms have subsided could be an
indication that he is responding well to medication; however, he has an insight level of 4
and could benefit from insight oriented psychotherapy. His physical examination was
normal, and his prognosis is most likely poor following his family history of mental
illness and non-compliance.
Multiaxial diagnosis.
• Axis 1: Bipolar 1, manic episode with psychotic features.

Due to the presence of :

1. Irritable mood.

2. Decreased need for sleep.

3. Grandiose delusions.

4. Talkativeness.

5. Impulsivity.
• Psychotic features were:

 Auditory hallucinations – second person commanding.

 Visual hallucinations.

 Bizarre behavior.
Differential diagnosis.
• Schizoaffective disorder.
 Ruled in due to presence of both mood and psychotic symptoms.
 Ruled out because there was no an interrupted period (2 weeks) of psychotic symptoms
without mood symptoms.
• Schizophrenia
 Ruled in due to presence of psychotic features. Ruled out due to presence of mood
symptoms.’
• Bipolar II disorder
 Ruled out because it didn’t meet criteria for major depressive episode and presence of
psychotic features.
• Axis II: no personality disorders and intellectual disabilities.

• Axis III: no general medical condition.

• Axis IV: Psychosocial stressors – separation with the wife, not knowing the wellness of
his son.

• Axis V: GAF 80 -71; if symptoms are present, they are transient and expectable reactions
to psychosocial stressors.
Management.
Admit to prevent harm to self and others.
Investigations.
Biological
• Toxicology screen – to rule out substances.
• Lipid profile – because he has been on antipsychotics that cause metabolic syndrome.
• HbA1c
• LFTs
• PITC
• VDRL
• CBC
• UECs
• Psychological: none.

• Social:

 Corroborative history on the onset of symptoms in the current admission.

 Corroborative history on the previous admissions.

 Corroborative history on the substance use.

 Corroborative history on the non – compliance to medication.


Treatment.
Biological.

• Verbal de-escalation.

• Rapid tranquilization - haloperidol 5mg IM stat that can be repeated after 1 hour (max 4 times).

• Suicidal watch.

• Quietapine 300mg PO BD.

• Sodium valproate 250mg BD; to be increased 2-3 days by 200 – 400mg/day.

• Fluphenazine decanote 12.5mg/2 weeks (inpatient) and then increase dose to 25mg to be
administered monthly after discharge.
• Psychological:

• Psychoeducation.

• Insight oriented psychotherapy.

• Social – none.
Prognosis:

• Poor prognostic factors – family history of mental illness, non – compliance to


medication that led to multiple relapses, male, low insight level, early age of onset (20
years).

• Overall prognosis is poor.

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