Group 3 Presentation.
Group 3 Presentation.
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
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 hobbies are watching football and this has not changed.
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.
• Sensory – fine touch, crude touch, temperature and pain sensation were normal in all
dermatological areas tested.
Cardiovascular system:
• 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.
• 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.
1. Irritable mood.
3. Grandiose delusions.
4. Talkativeness.
5. Impulsivity.
• Psychotic features were:
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 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:
• Verbal de-escalation.
• Rapid tranquilization - haloperidol 5mg IM stat that can be repeated after 1 hour (max 4 times).
• Suicidal watch.
• Fluphenazine decanote 12.5mg/2 weeks (inpatient) and then increase dose to 25mg to be
administered monthly after discharge.
• Psychological:
• Psychoeducation.
• Social – none.
Prognosis: