Case Presentation 11-12-2012


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Case Presentation 11-12-2012

  1. 1. By Dr.Ahmad Khattab Psychiatric Resident Under supervision of:Dr.Sonia Alzayat Psychiatric Consultant
  2. 2. “What truly is logic? Who decides reason? My quest has taken me to the physical, themetaphysical, the delusional, and back. I have made the most important discovery of my career - the most important discovery of my life. It is only in the mysterious equations of love that any logic or reasons can be found. I am only here tonight because of you, You are the only reason I am. You are all my reasons. Thank you. “ John Nash
  3. 3. a single male patient, aged 27 years old. He is an Egyptian citizen, lives in Alexandria,He Studied at Workers University. Graduated in 2007. But he has no work now.He has been admitted in our hospital by outpatient clinic psychiatrist under compulsiveauthority in 10th November 2012.
  4. 4. ‫‪From patient‬‬‫أنا زي ”جون ناش“ في فيلم “ ‪ ”Beaut if ul Mind‬بشوف حاجات مش موجودة..أنا عندي‬‫قدرات خاصة..لما بسلط طاقة المخ على حد يموت..أنا قدرت أموت 59 واحد شغالين‬ ‫مع الشيوعيين.‬ ‫أنا قدرت أنقذ أحمد ماهر و أحمد أبو الغيط و عاطف عبيد من الشيوعية.‬ ‫كلمت ربنا مرة واحدة و قاللي ”أنا أنت و أنت أنا“.‬‫أنا اكتسبت 6 لغات بس جلسات الكهرباء ضيعت كل البداع اللي عندي..و مرة قريت صيني‬ ‫صح من الشمال لليمين..و لغات الهيبيز و الشيتوس.‬ ‫فيه كتاب من 9 مجلدات عن الرجل اليسر..ده التشخيص بتاعي.‬‫الناس بتشاور عليا عشان قدراتي..بس أنا مش بخرج وسط الناس كتير عشان الناس اللي‬ ‫موتهم.‬ ‫الشيوعيين دفعوا 0005 جنيه عشان يذلوني..هم اللي حبسوني في أوضتي عشان قتلت‬ ‫عاطف عبيد.‬ ‫و أنا في أوضتي بسمع اللواء و واحد صاحبي في كلية الطب..دايما بيحيوني..كلهم‬ ‫أصدقائي..بيقولولي لو فيه خطر فألف زي المروحة..لو لفيت عكس التجاهأحيي‬ ‫الموتى..و الناس اللي أحييتهم بيقولولي ”أنت الرب اللي شفناه فوق“ لن ربنا قاللي‬ ‫”أنا أنت و أنت أنا“.‬ ‫انا الرجل اليسر..اللي هو المهدي المنتظر..اللي هو الرب..‬
  5. 5. ‫‪From relative‬‬ ‫الم‬‫خارج من المستشفى من شهرين قعد أسبوع كويس و هو حبس نفسه في حجرته و‬ ‫رافض الكل و الشرب معانا و بيقول إننا بنحط له براز في الكل و القهوة.‬ ‫و بيقول إنه لو خرج من أوضته الشيوعيين هيموتوه.‬‫رمى والده من على سطوح الدور الول عشان كان رافض يجي معانا المستشفى و دايما‬ ‫بيهددنا بالقتل و بيشرب سجاير كتير و رافض علجه.‬‫مشكلته بدأت في 7002 في آخر سنة في الكلية..كان عنده مادة..و نسي معاد الدور‬ ‫التاني فاضطر يعيد السنة كلها على مادة..فانهار و تعب نفسيا.‬‫كان بيشتغيل وقيت الكليية 3 شغلنات فيي وقيت واحد.و بينزل يقعيد ميع أصيحابه على‬ ‫القهوة.و مهتم جدا بنفسه..في أول السنة الدراسية يجيب بألف جنيه هدوم جديدة.‬‫بعد التعب مابقاش يخرج مع أصحابه..و يقوللي قوليلهم مش موجود..أنا لو نزلت الشارع‬ ‫الشيوعيين هيموتوني.‬‫كان مهتم جدا بمظهره و يرتب أوضته..و غاوي كمبيوتر يقعد عليه..و يصلحه..دلوقت أهمل‬ ‫نفسه.‬‫خطبت له مره في أول تعبه من 5 سنين لما لقيته منطوي..كان حالة متقلب..أوقات يفرح‬‫قوي إنها بتكلمه أو لما بيزورونا..و بعدين بقى رافض يتصل بيها أو يزورها..الخطوبة‬ ‫قعدت شهرين و انتهت.‬
  6. 6. The condition deteriorated gradually during last 2 months after patient stopped his psychiatric medication byhis own will one week after discharge from our hospital, showing some irritability, tendency to stay in hisroom alone, afraid of people to kill him, He was aggressive against his family members, Refuse eating withthem as he was suspicious of food poisoning. So he threatened to kill his family.Now, He claims that he can see non existing things like “John Nash” in “Beautiful Mind” movie. Also he saysthat he has a special gifts and power of killing and revival of dead people, and because of these power UNasked him to work together, but he refused.He claims that he was speaking at least 9 languages but he forgot them during the last admission in ourhospital “Last September” because of ECT..
  7. 7.  Psychiatric history:The condition started about 5 years back, Seeked advice in private clinics.Admitted to our hospital 2 times before this one.1st Admission: 13th September 2011 – 1st October 2011 Diagnosed as “Schizophrenia” and controlled by Atypical antipsychotic “Resperidone tab. 6mg/day” , “Benzotropine mesylate tab. 2mg /day” and long Acting antipsychotic “Haloperidol decanause 2amp./15 days”.2nd Admission: 19th July 2012 – 1st September 2012 Diagnosed as “Schizophrenia” and controlled by Atypical antipsychotic “Resperidone tab. 6mg/day” , “Benzotropine mesylate tab. 2mg /day” and long Acting antipsychotic “Haloperidol decanause 2amp./15 days”. 6 sets of ECT was added to treatment after 3 weeks of admission and improved. Substance: No evident history about substance abuse. Medical: No evident history of any chronic medical disease or admission in general hospital. Surgical: No evident history of any major surgical operation or Head Trauma.
  8. 8. His father is an old man with history of a psychiatric disorder, but he stopped his treatmentseveral years before, and he is mentally stable now without treatment, But he is not workingnow.His mother is an old woman, house wife with no history of any psychiatric disorder.Negative consanguinity.Our patient is the 4th in order of siblings, 2 brothers & 2 sisters.His elder brother is also a psychotic patient, mentally stable and functioning on treatment.
  9. 9. Pregnancy: No history of any diseases or medications or trauma to his mother duringpregnancy.Delivery: NormalEarly Development: No evident history of any proplems.Neurotic trait: No evident history.Child abuse: No evident history.Scholastic history: He dropped in the last year in university, and graduated in 2007.Military History: Exemption from conscription.Occupational history: 3 jobs at the same time divided into 3 shifts duringuniversity study as a security & a worker .Sexualhistory: No evident history.Marital History & offspring: Not married.
  10. 10. No history of any illegal problems.He was friendly, Loitering out with friends and go out to coffee shop.He was spending his time using computer, and he could fix any problems.He was smoker, and became a heavy smoker after his disorder, he smokes about 5 packs ofcigarettes (100 cig.) per day..??He wasn’t religious, No pray or Fasting.
  11. 11. Patient is conscious, alert, calm and cooperative, within average general appearance, oriented to time,place & personality. He has an intact memory (Immediate, Recent & Remote).His speech is induced, coherent with relevant answers.He has poor judgment, poor insight.He thinks magically with bizarre delusions of grandeur, persecution and reference.Auditory & Visual hallucinations.Mood congruent delusions & hallucinations and flat affect.
  12. 12. Blood pressure: 110/70 Pulse: 80 b/mAbdominal examination:Lax abdomen, no organomegaly felt by palpation.Chest examination:No abnormalities detected.Investigations results:In 5/12/2012 :Hb 14.5 gm% - RBCs 4970000/cmm - Platelets 240000/cmm - WBCs 5.300/cmmIn 12/11/2012 :Fasting blood sugar 85 mg% - SGPT 9 U/I
  13. 13. Chronic Relapsing Schizophrenia
  14. 14. Psychopharmacology:We started by:Clopexol acquafase Amp. IM/ 15 daysResperidone tab. 6mg/dayBenzotropine mesylate tab. 4mg/dayClozapine tab. 25mg /day increased gradually to 100mg /day divided into 2 doses.In 6/12/2012 we started ECT sessions, as his condition showed poor improvement, and he hashistory of better improvement on ECT.He received 2 sessions of 6 sessions recommended till now.Psychosocial intervention:Because of his social withdrawal, I think it’s better to start group therapy plus occupational therapygradually for rehabilitation.After discharge, day care should be continued, and it’s challenging to have that in our hospital.
  15. 15. ‫جزاكم ا خيرا‬ ‫‪Thank You‬‬