Case Conference @ Treatment Resistant Schizophrenia.pptx

 Presenter- Dr. Vasu Mishra
 SR in-charge- Dr. Swati Chaudhary
 Chairperson- Dr. Navratan Suthar
CASE
CONFERENCE

AIM
To discuss a case of treatment resistant
schizophrenia and it’s management

IDENTIFICATION DATA
Sociodemographic details
AGE 20 years old
GENDER Male
RESIDENCE Kawas, Barmer, Rajasthan
RELIGION Hindu
MARITAL STATUS Single
EDUCATION 12th pass
OCCUPATION Unemployed
TYPE OF FAMILY Nuclear
SOCIO-ECONOMIC STATUS LMSES

DATE OF ADMISSION 15/02/2021
MODE OF ADMISSION Supported, Section-89 MHCA
REASON OF ADMISSION Diagnostic clarification and treatment
rationalization
ADVANCE DIRECTIVE No
DATE OF DISCHARGE 26/3/2021

IDENTIFICATION DATA
Informants:
1. Self
2. Father, Mr Ganesh Kumar, 46 year old male, currently unemployed, previously owned an electric
shop and is living with patient since birth
3. Past medical records
• Information provided is reliable and adequate

CHIEF COMPLAINTS
According to the patient:
 Koi takleef nahi hai, pitaji layen hain
According to informant:
 Ajeeb baatein aur vyavhar karta hai
 Khud mein hi badbdata hai aur hasta hai 3 years
 Bewajah gussa krta hai, galeegalauj aur marpeet karne lga hai

ILLNESS DETAILS
1. Total duration of illness 3 years
2. Onset Insidious
3. Course Continuous and progressive
4. Precipitating factor Not elicitable

HOPI
Patient was maintaining well till January 2018 when he was studying for air force entrance examination at
a coaching centre in Jodhpur. His mood until then was neither overtly cheerful nor sad
Around January 2018, his father got a call from his coaching centre that the patient was behaving
differently. They complained that the patient was taking abnormally long time to eat his meals in the mess
He would frequently be observed muttering to himself, even in the absence of any company. People also
noticed him indulging in bouts of laughter and making expressive hand gestures, seemingly directed
towards the empty air
When questioned about the reasons behind his peculiar behavior, he offered no explanation whatsoever

HOPI
His roommates informed that for past 3-4 days he started spending lot time in bathroom. He would often
been seen taking his books along with him there which was not his usual self
He would sit like a yogi and ask his roommate not to disturb him as he was doing his “dhyan”and would
not elaborate anything further when asked
He would shout shlokas in sanskrit loudly and would often talk on science and religion which others find
difficult to comprehend and would appeared lost in his own thoughts
Further was brought to aunts house and there he was taken to private psychiatrist where diagnosis of acute
transient psychotic disorder was made and was prescribed oral medication for 5 days

With medication he would remain drowsy and would only eat meals and kept quiet for most of the day
In follow up medication was prescribed for 15 days more. At the doctors chamber he told that he wanted
to do PHD and teach lot of children but didn’t came forward with any rationale for the same
Seeing his excessive lethargy, his father decided to taper the medications by himself by reducing the dose
in half
Within 2 days of reducing medications, the patient developed increased irritability and had episodes of
unprovoked anger and would even become physically abusive on family members
HOPI

He also continued repeatedly going to the bathroom and would sometimes spend 1-2 hours inside and
would come out in similar state as he went inside
Gradually he reduced helping his parents in the household chores which he previously used to do
Anger outbursts and verbal altercations occurred once or twice in 1-2 weeks and would appear irritable and
would continue muttering irrelevant
He continued taking oral medications(compliance ensured) at home under the supervision of his parents.
Gradually his irritability reduced along with reduced talking and smiling to self
HOPI

HOPI
By November 2018 his father reported 15-20% improvement in terms of mood and behaviour
His interaction was still reduced and non spontaneous. He would keep to himself most of the day. He also
would appear withdrawn during festivals and family occasions
He continued maintaining in the similar state till March 2019 when his father decided to consult a local
private psychiatrist for further treatment in Barmer as he felt that Jodhpur was far for regular follow ups and
also there was no further improvement that could be seen

He was prescribed oral medications(which included tab Fluoxetine 20 mg) and sent home
Within 10-15 days of starting these medications, the patient had an episode of spontaneously crying without
any reason and said that he did not wish to live at home anymore and would either commit suicide or
become a sanyasi(no further elaboration)
This episode lasted for 20-30 minutes and the patient spontaneously stopped crying. No further information
is forthcoming from the patient about this incident and his father stopped the medication
Then they consulted another psychiatrist in jodhpur, with medications again similar improvement in terms
of irritability and anger outburst was reported
HOPI

Even after repeated persuasion he would only reply in one word answers or a few sentences
Around July-August 2019, his irritability started increasing again(medications were continued). He again
started muttering and talking to self when no one was around
He would often stare at himself in the mirror and do hand gestures and smile inappropriately and didn’t
gave any reason for his behaviour when being asked by family members
He would often go to the terrace of the house and would play chess by himself and would mutter
incomprehensible things and laugh even when no one was around to play with him
HOPI

Only once as per brother he told him-”mujhe awaze sunai deti hai” but on further asking he didn’t
elaborated or gave any further information
He would not cut his nails and would rarely do personal hygiene related activities even after repeated
persuasion
In the year 2020, his symptoms persisted of occasional muttering to self and inappropriate smile along with
decrease interaction with family members
HOPI

HOPI
He keeps going out of his home to specific places continuously for a few days and would choose another
place for the next few days and would spend a significant part of his day outside the home on most days of
the week loitering around and talking to himself
Around September 2020, he started eating specific foodstuffs at specific times during the day every day, for
eg. For a few days he would eat poha at 4pm everyday followed by papad for a few days at the same time

HOPI
Family members also reported observing him repeatedly picking the glass up, drinking a sip of water, and
putting it down repeatedly. No h/o of excessive drinking of water was forthcoming
He would sometimes dance without any reason and when asked he would say he is doing ‘shiv-nritya’ and
did not elaborate on why he was doing the same
Further his father brought him to AIIMS Jodhpur where diagnosis of he was started on tab olanzapine was
started 5 mg and was hiked to upto 20 mg over 2 months with no improvement reported
He was further admitted in our ward for further assessment and management

NEGATIVE HISTORY
• No H/S/O thought coming or leaving patients or being heard aloud against his will
• No H/S/O of maintaining odd or bizarre postures for long duration.
• No H/S/O of persistent pervasive low mood or decrease interest in previously pleasurable activities, etc.
• No H/S/O periods of increased activity, overspending, reduced need for sleep, etc.
• No H/S/O irrational repetitive intrusive thoughts or actions.
• No H/S/O head injury, ENT bleed or seizures
• No H/S/O any substance use

PAST MEDICALAND PSYCHIATRIC
HISTORY
• No other past h/o medical/surgical illness in the patient.

TREATMENT HISTORY
Date Medication Compliance Improvement Side-effects
January-
February
2018
Tab. Valproate 500 mg BD
Tab. Haloperidol 10 mg BD
Tab. THP 2 mg TDS
Irregular Compliance,
father reduced dose i/v/o
sedation
No improvement
Sedation
March
2018
Tab. Olanzapine 15 mg HS
Tab. Valproate 1000mg
Tab. THP 2 mg TDS
Compliant 10% improvement,
reduced irritability
sedation
May To
July
2018
Olanzapine dose increased
to 20 mg HS
Compliant 15-20% improvement
sustained
As above

TREATMENT HISTORY
August 2018-
september 2018
Tab. Olanzapine 25 mg
HS
Compliant 15 % improvement, reduced
irritability, self muttering,
laughing, irrelevant talks
continued intermittently.
None
October 2018 Tab. Valproate 200 mg
(gradually increased)
HS (gradually tapered)
Compliant Sustained as above None
November 2018 Tab. Valproate 250 mg
HS
Compliant Same as above None

TREATMENT HISTORY
December 2018 Tab. Olanzapine 7.5 mg HS
Tab. Valproate 250 mg
February – March2019 Tab. Valproate 250 mg
Mid March 2019 Tab. Fluoxetine 20 mg BD
Compliant talks of suicide None
April 2019 Tab. Olanzapine 15 mg HS
Compliant 15 % improvement Weight Gain

TREATMENT HISTORY
May-June2019 Tab. Valproate 300 mg
Compliant Sustained Weight gain
July 2019 (15 DAYS) Tab. Valproate 500 mg
Tab. Amisulpride 100 mg Compliant
Better interaction None
July 2019(rest of the
month)
Tab. Valproate 500 mg BD
Tab. Amisulpride 100 mg
Compliant sustained None
August 2019
Tab. Chlorpromazine 50 mg BD
Tab. Sodium Valproate 1000 mg Compliant
Increased irritability,
anger outburst, no
further improvemnt
None

TREATMENT HISTORY
September –November
2019
Tab. Amisulpride was increased
from 200 mg to 300 mg.
Compliant No further
improvement
None
December 2019 – May
2020
Tab. Sodium Valproate 1000 mg
?? Long acting injectable was
prescribed
Compliant Reduced irritability, no
further improvement.
None
June – September
2020
Compliant No further
improvement
None
October -November
2020
Tab Olanzapine 10 mg HS built to
20 mg in 1 month
Compliant Reduced irritability, no
further improvement
None

TREATMENT HISTORY
Prior adequate trial of Tab. Haloperidol, Tab. Olanzapine, Tab. Amisulpride was given
with no significant improvement

FAMILY HISTORY
Patient lives in a nuclear family with his father, mother, younger brother (12 yrs of age) in a village 30
kms away from Barmer city
His elder brother lives with his father’s elder brother as he has adopted him when he was young
h/o of IPR issues between the father and mother due to lack of a reliable source of income for the past 5-
6 years
Father had an electric shop on rent which was not running well since lockdown, so he had to close it
down. Mother works as a tailor and that is a significant source of income
No H/o of any psychiatric or medical illness in the family was forthcoming
Family members understands the nature of illness and its need for treatment. Although there were
frequent critical comments from mother

• Type of family: Nuclear
• SES: Lower middle SES according to modified Kuppuswamy scale 2020.
• Chief earning member of family: Patient’s mother
• Chief decision maker of the family: Patient’s father
• Chief care giver of the patient: Patient’s father
• Monthly Income: Rs. 15k
FAMILY HISTORY

PERSONAL HISTORY
 Birth history: antenatal period was uneventful, home birth, FTNVD, cried at birth
Early developmental and childhood history: all milestones attained on time, no h/o mental/physical/surgical
illness in early childhood/ no h/o neurotic traits/ truancy/ disobedience

ACADEMIC HISTORY
Started school at the age of 5, average scholastic performance
H/o change from Hindi medium to English medium in 11th class where he faced issues due to the
language and different socioeconomic status of his peers, and also had a decline in scholastic
performance in 11th standard; however, he was able to cope better in 12th class and scored 78% marks
Took a drop year to decide what to do further. During this period, he started watching videos on
philosophy, religion and science on you-tube and also started reading various religious texts and
mythology novels which was unlike his previous self
Joined a coaching institute in December 2017 at jodhpur to prepare for airforce entrance exams on
persuasion by father. Maintained well for a month and was able to cope with studies according to father
before onset of symptoms in January 2018

Occupational History: has been unemployed after school due to illness, on persuasion by father he
learnt a mobile repairing course in march 2019, but did not take up any job thereafter
Sexual history: never masturbated and further information was not forthcoming
Marital History: Unmarried. Had an online relationship with a girl from another city since 2017.
Continued chatting with her on the phone frequently till 2018 until onset of symptoms. Tried contacting
her in January 2018 through text messages but as girl was informed by the patients family about his
illness, she stopped responding and they lost contact with her thereafter. No information forthcoming
from the patient
Substance use history: None
PERSONAL HISTORY

TEMPERAMENT
 Activity level: same as peers
 Rhythmicity: predictable
 Distractibility: low (able to sit long hours for studies)
 Approach/Withdrawal: Withdraws (hesitated talking with strangers, distant relatives)
 Adaptability: average
 Persistence: High (would stick to task, completed homework on time)
 Intensity of reaction: high (reacts intensely when reprimanded)
 Threshold for responsiveness: average
 Quality of mood: neither overtly cheerful nor sad
➢Impression: Easy child

GENERAL PHYSICAL EXAMINATION
PHYSICAL EXAMINATION - Vitals:
Pulse Rate: 96/min, BP: 118/78 mm Hg, Temp: 98.6 F, RR: 19/min.
Height: 182cm.
Weight: 65kg.
BMI: 19.6kg/m2
General condition: Alert and Conscious.
Waist circumference: 72 cm
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, oedema.
SYSTEMIC EXAMINATION - WNL.

MENTAL STATUS EXAMINATION
• General appearance and behavior:
oAverage height and average built
oWell clad and well kempt
oNormal gait
oConscious
ocooperative
oInappropriate smile + towards doctors as well as strangers
oRapport- established with difficulty.
oEye to eye contact- Initiated but not maintained

• Psychomotor activity: decreased
• Speech:
o Non spontaneous.
o Tonal fluctuance was absent.
o Rate, Amount & Volume : Decreased.
o Reaction time : increased.
o Comprehensible and relevant

• Mood /affect:
o Subjective : "Man thik hai"
o Objective : Blunt
o Range : restricted
o Reactivity : Absent
o Congruent to thought
o Inappropriate to surroundings

• THOUGHT:
Stream: NAD
Form :
• Dr: Hello k, kaise ho?
• Pt: Initiates eye contact, smiles inappropriately and then looks downward and after a pause replies thik
hun sir
• Dr: Ye btao abhi kaun sa tyohar ane wale hai?
• Pt: Jahan tak mujhe pta holi ane wali hai (after a pause)
• Dr: Han ok, aap btao holi ke bare mein kya pta hai aapko

•Pt: (again after a pause)……Sir, holi mein holika dahan hota hai, vishnu ji ne prahalad ki madad ki
thi,vishnu sir meri class mein ek ladka padta tha jise meri nahi banti thi, ghar wale smajhte nahi hai, maine
sab kuch likh rakh hai file mein aapni, main toh janta hun batman ki shooting india mein hui hai, papa ko
lgta hai mujhe schizophrenia naam ki beemari hai, dashrath aur drishrashtra ki aapas mein fight krayenge
toh sari cheeze aapne aap clear ho jayengi sir, gita h sbka ilaj hai, gita se milna haui mujhe
Impression: Derailment v/s Tangentiality(loosening of association seen)

CONTENT:
• Dr: Kya koi pareshani hai abhi aapko?
• Pt: Nahi koi pareshani nhi hai
• Dr: Kya koi dikkat hai jiskiwajah se aapko hasptal ane ki zarrorat hui?
• Pt: Nahi koi dikkat nahi hai
• Dr: Ghar vale keh rhe the ki aap jab bhi bahar nikalte hai to sir chupa kar nikalte hai iska kya karan
hai
• Pt: Chamgadar se bachta hun
• Dr: Chamgadar se kyun bachte ho

• Pt: chamgadar radiation ka use karte hain, andhe hote hain, toh unn radiation se vo muj pr najar
rakhte hai
• Dr: acha par ap pr najar kyu rakhte hain
• Pt: kyunki maine kafi kuch gyan prapt kr liya hai gita pad kr to sarkar rakhwa rahi hai najar
• Dr: sarkar ko kya nuksan ho skta hai apse aap pr hi kyu najar rakhvaya rahi h vo , geeta to bahut
longo ne padhi hui hai
• Pt: pta nahi sarkar kuch bhi kr skti hai jab main so raha hota hun tbhi dur se radiation aayene honge
or inhi radiations se sarkar ne pta kr liya hai meri knowledge ka

• Dr: Par kya aisa possible hai, bat to radiations ko andhere me rasta dekhne k liye krti hai to us se vo
aap pr najar kaise rakh ri hai
• Pt: Apko nahi pta hai sir bat ki radiations ko decode krke sari info nikal lete hai or sarkar tak pahucha
dete hai
• Dr: Par science to ye nahi kehti
• Pt: Tab sir science ko update krna padega
• IMPRESSION : Bizzare delusions.
• POSSESION OF THOUGHT : NAD

PERCEPTION
• Dr: Jab aap akele hote hai or aas pass koi ni hota hai tab kano me shor ya awazien sunai padhti hai jo sirf
aapko hi sunaai dein?
• Pt: Han, ati hai..
• Dr: In awazon k bare me or vistar se batao
• Pt: Jo bhi main kaam krta hun wo aawaz wahi repeat kr deti hai bus sir.
• Dr: Kya ye male ki hoti hai ya female ki?
• Pt: Kabhi male toh kabhi female
• Dr: Aur kahann se ati hai aawaz aapko?
• Pt: Awaz toh bahar se ati hai kabhi dayi kbhi bayein taraf se kamre mein h
• Dr: Okay, ye awaaz kyaa apse kuch baat karti hai?
• Pt: Han..
• Dr: Kya bolti hai ye awaaz apko?

PERCEPTION
•Pt: Dekho ab ye baith rha hai , ab sone ja rha hai muj pr hasti bhi hai
•Dr: Ye awazien ek dum saaf sunayi de rahi h jaise abhi meri awaj sun rahi h
•Pt: Nahi itni saaf ni hai par kbhi saaf hoti hai kbhi Dheere se bolti h
•Dr: Kya ye awazien apke man se uthti hai ya bahar se aati hai aur kano me sunayi deti hai ?
•Pt: Bahar se aati hai or kano me sunayi deti hai
•Dr: Kya kabhi rokne ki koshish ki in awazo ko?
•Pt: Han, nahi rukti, mai khud se bolta hun aisa mat karo, akele baith kr geeta padhta hun kuch fark ni padta
•Impression: 2nd person auditory hallucination(running commentary type)

NEUROCOGNITIVE FUNCTION
1. Orientation: Oriented to time place and person.
2. Attention and concentration:
• Able to perform 5 digit forward (1-6-4-9-2)
• Able perform 3 digit backward (4-1-7)
• Serial subtraction test:
◦ 100-7 :did till 86 , said further calculation will require “mathematical induction”
◦ 40-3 : did till 34, refused to do further, said don’t try to hypnotize me
◦ 20-1 : completed in 10 seconds , no mistake
Impression: Attention arousable and ill sustained

3. Memory:
• Immediate recall: 3 words given- imperial, dustbin, blue
Able to repeat 3 words
• Registration intact
• Delayed recall: intact
• Recent memory:. asked what he ate last night, corroborated with father
• Remote memory:. asked about the name of first school, marks in 12th boards
• Impression: Intact

4. General fund of knowledge:
◦ Cities of India: Delhi, Mumbai, Jaipur, Jodhpur, Bikaner
◦ CM of Rajasthan : Ashok Gehlot
◦ 5 rivers: Ganga, Yamuna, Saraswati, luni, kaylana
◦ 5 seasonal fruits: mango, gaajar, orange, ber, angoor
Calculation:
• Simple arithmetic: 7×2= 14, 4+3= 7, 10-6=4
• Complex arithmetic: Complex arithmetic: did not do any calculation, asked for a paper and wrote a
mathematical equation instead
• Comprehension: Intact, checked by three command test

5. Abstract thinking:
Proverb test:
• 9-2-11 hona: Bhaag jana
• Bandar kya jane adrak ka swad :naachnaa jane aangantedha
• Oonth ke muh me jeera hona: oonth ko pani peene ki aadat nhi hoti isliye jeera khata hai
Similarity test:
• Train and Bus: koi samantha nahi hai
• Dog and Cat: dono pati patni hai
Impression: Abstract thinking impaired

6. Judgement:
•Social judgement: Does not greet back, smiles inappropriately
•Test judgement: Letter test: letter box mein dal dunga
Fire test: aagwali gadi ko bulaenge
•Personal judgement: Yaha se jaane k baad kya karoge aap?
Film producer banunga, Mumbai jaunga,kuch script already likh chukka hun
Impression: Personal judgement impaired

7. Insight:
• Dr: karan koi beemari hai kya aapko ?
• Pt: nahi, sir jaisa ki maine btaya pitaji le ayen hain, mujhe koi pareshani nahi haii, main
ekdam thik hun
Impression: Grade 1

DIAGNOSTIC FORMULATION
•20yrs old single, male, studied till 12th class, belonging to Hindu nuclear family of LMSES, resident of
Barmer, with easy premorbid temperament, presented with psychiatric illness-insidious onset and
continuous course characterized by hallucinatory behaviour, disorganized speech, bizarre ideas for past 3
years associated with anger outbursts, paucity of speech, social withdrawal, loss of interest, and poor social
-functioning. On GPE: BMI-19.6 kg/m2, on MSE staring gaze, inappropriate smile, ETEC initiated but not
maintained, rapport established with difficulty, decreased PMA, bizarre delusions, 2nt person auditory
hallucinations(running commentary type), impaired personal judgement, impaired abstract thinking and
grade 1 insight

PROVISIONAL DIAGNOSIS
6A20.00- Schizophrenia, first episode, currently symptomatic

COURSE AND MANAGEMENT IN
WARD
GOALS DURING STAY IN WARD
Establish
therapeutic
alliance
Investigations-
Routine
investigation
Further
exploration
of history and
diagnosis
Rationalization
of
pharmacotherapy
Psychoeducation
and supportive
sessions with
family members
Behavioural
intervention

INVESTIGATIONS
Hb 13.8 gm/dl
TLC 9360/ul
Platelets 313000/ul
SGOT/SGPT 19/11.6 IU/l
Urea/Creatinine 21/0.72 mg/dl
Lipid Profile TC- 155 mg/dL, TG- 91 mg/dL, HDL- 45 mg/dL, LDL- 107 mg/dL
RBS 118 mg/dL
HbA1C 4.8%
Na+/K+/Cl- 136 / 3.78 / 105 meq/l
Vitamin D 20.91 ng/ml
Vitamin B12 378 pg/ml

6A20.00- Schizophrenia, first episode, currently symptomatic(according to
ICD 11)
Hypovitaminosis D
FINAL DIAGNOSIS

CRITERIA MET ACCORDING TO ICD 11

59
Date 1st week
Status • Routine investigations & Exploratory sessions
• Psychoeducation to family members done
• Monitoring of vitals done
• PANSS 93(30+35+28)
Medications • Tab. Clozapine 75 mg (25-X-50) initially and was increased 25 mg every fourth
day after CBC
• Tab. Olanzapine 20 mg HS continued
• Tab. Clonazepam 0.5 mg SOS
• Cap. Vitamin D3 60k IU once a week for 8 weeks was added
Issues • Increased sedation on the BD dosing of Clozapine
• Decreased appetite
• Anxiety symptoms
• Decrease interaction at times

60
Date 2nd week
Status • Psychoeducation continued and other family members were included on telephonic
communication
• Psychoeducation regarding Clozapine was also along with leaflet
• At around dose of 150 mg of Clozapine patient developed increase in pulse rate
around 125/ min
• Decreased frequency of anxiety symptoms
• Muttering to self and inappropriate smiling had reduced
• Activity scheduling done
• PANSS-84(28+33+ 23)
Medications • Tab. Clozapine 125 mg (25-X-100) initially and was increased 25 mg every fourth
day after CBC
• Tab. Clonazepam 0.5 mg SOS
Issues • Difficulty in engaging him to follow activity scheduling

61
Date 3rd week
Status • Token economy was tried, a listed of favourable and desired tasks possible in ward setting
were noted, points were given to each tasks and that much tokens were given and on
completion of that much points was given verbal praise by doctor as wells as his father.
• Muttering was altogether absent, occasional incidences of inappropriate smiling
• No auditory hallucination reported
• For hypersalivation at night time advised to keep towel on side ways sleeping position
• Regular monitoring was continued
• PANSS-80(25+33+ 22)
Medications • Tab. Clozapine 175 mg (25-X-150) initially and was increased 25 mg every fourth day after
CBC
• Tab Metoprolol 25 mg BD
• Tab Clonazepam 0.5 mg SOS
• Cap Vitamin D3 60k IU once a week for 8 weeks was added
Issues • Increase in pulse rate for which respective consultations were taken
• Not engaging in activities
• Hypersalivation at night time

62
Date 4th week
Status • No muttering to self or inappropriate smiling.
• Token economy was continued
• Psycho education sessions was completed and care giver burden was addressed
• PANSS-78(23+33+ 22)
Medications • Tab. Clozapine 225 mg (25-X-200) initially and was increased 25 mg every
fourth day after CBC
• Tab. Olanzapine 20 mg HS continued .
Issues • Negative symptoms predominated
• Very difficult to get him engaged in doing activities

63
Date 5th week
Status • Positives symptoms had significant improvement
• Negative symptoms continued similarly
• Olanzapine was cross tapered at 250 mg level of clozapine at stopped in span of a
week
• Pulse rate remained around 90 to 100 range
• PANSS-76(22+32+22)
Medications • Tab. Clozapin 275 mg (25-X-250) initially and was increased 25 mg every fourth day
after CBC
Issues • Negative symptoms

TREATMENTAT THE TIME OF
DISCHARGE
• TAB. CLOZAPINE 300 mg (X-X-300)
• TAB. CLONAZEPAM 0.5 mg SOS
• TAB. METOPROLOL 25 mg BD
• Supervise medications
• To continue following token economy
• To do weekly CBC report up to 18 weeks thereafter once in two weeks
PANSS-75(22+32+ 22)

1) Clozapine was raised to 325
2) Clozapine was raised till 350
3) Clozapine raised to 375, reported occasional
muttering to self
4) Clozapine raised to 400
CBC was done regularly and
monitoring for side effects done
regularly
Tab. Metoprolol 25 mg BD was
continued

7) Tab Amisulpride was added 50 mg then
to 100 mg Reported 40 percent
subjective improvement
Plan is to build up Tab Amisulpride

Case Conference @ Treatment Resistant Schizophrenia.pptx

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Case Conference @ Treatment Resistant Schizophrenia.pptx