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Psychiatry Case Presentation (Depression).pptx

Case discussion of Adjustment disorder with moderate depression done for the Diploma course in Community Mental Health by CIP, Ranchi.

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CASE PRESNTATION
for
Diploma in Community Mental Health
Dr. IMMANUEL JOSHUA
Junior Resident
Dept. of Community Medicine
Banaras Hindu University
Varanasi-221005
CIP Digital Academy
SOCIO-DEMOGRAPHIC PROFILE
 Name: Mr. U
 Age: 25years
 Gender: Male
 Religion: Hindu
 Marital Status: Married
• Education: BA
• Occupation: Salesman
• Socioeconomic status: Middle
• Place: Chiraigao, Varanasi
• Informants: Self and Mother
CHIEF COMPLAINTS
 Easy fatigability x 4 months
 Sadness of mood x 3 months
 Decreased sleep x 3 months
 Decreased appetite x 3 months
 Decreased social interaction x 2 months
 Loss of interest in pleasurable activities x 2 months
 Ideas of guilt x 2 months
PRESENTING PROBLEMS
• Onset : Acute
• Course : Continuous
• Duration: 3-4 months
• Predisposing factor : Family history of depressive disorder
• Precipitating Factors : Quarrel or argument with his wife
• Perpetuating factors : Wife is not taking care
• Patient was apparently asymptomatic 6 months back when he got married.
• His wife is a housewife and she is not well versed with household chores.
• He felt stressed due to his allegation that his wife is not taking care of him
and that his wife comments on his mother.
HISTORY OF PRESENTING ILLNESS
 Decreased sleep:
• He developed difficulty in sleep initiation and maintenance.
• He falls asleep after 1-2 hours of lying in bed and his sleep was
disturbed frequently due to thinking of daily happenings at home.
• He wakes up several times during the night.
• He could hardly sleep for 4 hours in a day as compared to his previous
sleep of 6-7 hours.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 6

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Psychiatry Case Presentation (Depression).pptx

  • 1. CASE PRESNTATION for Diploma in Community Mental Health Dr. IMMANUEL JOSHUA Junior Resident Dept. of Community Medicine Banaras Hindu University Varanasi-221005 CIP Digital Academy
  • 2. SOCIO-DEMOGRAPHIC PROFILE  Name: Mr. U  Age: 25years  Gender: Male  Religion: Hindu  Marital Status: Married • Education: BA • Occupation: Salesman • Socioeconomic status: Middle • Place: Chiraigao, Varanasi • Informants: Self and Mother
  • 3. CHIEF COMPLAINTS  Easy fatigability x 4 months  Sadness of mood x 3 months  Decreased sleep x 3 months  Decreased appetite x 3 months  Decreased social interaction x 2 months  Loss of interest in pleasurable activities x 2 months  Ideas of guilt x 2 months
  • 4. PRESENTING PROBLEMS • Onset : Acute • Course : Continuous • Duration: 3-4 months • Predisposing factor : Family history of depressive disorder • Precipitating Factors : Quarrel or argument with his wife • Perpetuating factors : Wife is not taking care
  • 5. • Patient was apparently asymptomatic 6 months back when he got married. • His wife is a housewife and she is not well versed with household chores. • He felt stressed due to his allegation that his wife is not taking care of him and that his wife comments on his mother. HISTORY OF PRESENTING ILLNESS
  • 6.  Decreased sleep: • He developed difficulty in sleep initiation and maintenance. • He falls asleep after 1-2 hours of lying in bed and his sleep was disturbed frequently due to thinking of daily happenings at home. • He wakes up several times during the night. • He could hardly sleep for 4 hours in a day as compared to his previous sleep of 6-7 hours. HISTORY OF PRESENTING ILLNESS Dr. IMMANUEL JOSHUA (BHU) 6
  • 7.  Decreased appetite: • He lost his appetite and ate only 2-3 roti compared to his previous appetite of eating 6 roti per day. • He ate only on repeated persuasion of his mother. HISTORY OF PRESENTING ILLNESS Dr. IMMANUEL JOSHUA (BHU) 7
  • 8.  Sadness of mood: • He started remaining sad and gloomy all day. • He did not like talking to family members particularly his wife. • He did not like to go to work (salesman in a grocery shop)  Easy fatigability: • He felt tired the whole day and easily got tired after working for a while. • He preferred lying in bed whenever he could spare time. HISTORY OF PRESENTING ILLNESS Dr. IMMANUEL JOSHUA (BHU) 8
  • 9.  Decreased social interaction: • He did not like talking to his brother or sister over phone.  Loss of interest in pleasurable activities: • He lost interest in watching television and stopped playing badminton with friends. • He preferred sitting idle. • He did not like going out for walk with his dog. HISTORY OF PRESENTING ILLNESS Dr. IMMANUEL JOSHUA (BHU) 9
  • 10.  Ideas of guilt: • He started regretting because his father started asking about his irregularities in his daily work. • He felt cornered because his father was repeatedly comparing him with his friends. HISTORY OF PRESENTING ILLNESS Dr. IMMANUEL JOSHUA (BHU) 10
  • 11. • He was brought to Psychiatry OPD in BHU 1month back (after a neighbour asked them to consult) for the above complaints and he was started on treatment. • Now he is brought for follow up after 1 month and is admitted in Psychiatry ward for further management. • Treatment given: TREATMENT HISTORY Drug name Dose 1)T. ESCITALOPRAM 2)T. CLONAZEPAM 20mg/day 0.5mg/day Overall compliance to treatment is adequate No h/o of any significant side effects Dr. IMMANUEL JOSHUA (BHU) 11
  • 12.  No H/O diabetes/ HTN/ T.B./ prolong fever /seizure/mass lesion affecting CNS  No H/O increase talk/ over-expenditure  No H/O over-generosity/ over-religiosity / over-planning  No H/O suspiciousness, hearing of voices  No H/O thoughts being heard aloud loud/ mutism /incoherence NEGATIVE HISTORY Dr. IMMANUEL JOSHUA (BHU) 12
  • 13.  No significant history of any psychiatric illness in the past PAST HISTORY PAST MEDICAL & SURGICAL HISTORY  No significant medical & surgical history Dr. IMMANUEL JOSHUA (BHU) 13
  • 14. FAMILY HISTORY Family of Origin Family of In-Laws 32 years Married Intermediate 28 years Married Intermediate 25 years Married BA 23 years Married Housewife 19 years Unmarried Graduate Dr. IMMANUEL JOSHUA (BHU) 14
  • 15.  Type of family : Nuclear  No of family members : 5  Family concept about illness: His family members think that he is very shy, sensitive and his tolerance of stress is low.  Family stress : Nil (as per respondent)  Substance abuse :Nil  Living arrangement : Family lives in a pucca house in Chiraigao FAMILY HISTORY  Head of family : Patient’s father  Chief caregiver in family : Patient’s mother  Chief decision maker : Patient’s father  Chief earning member in family: Father  Father has H/O depressive disorder Dr. IMMANUEL JOSHUA (BHU) 15
  • 16.  Birth history: (from his mother) • Patient was born at 9 months by normal vaginal delivery. • Cried immediately after birth. • All milestones were attained at right time .  Childhood history: • No h/s/o hyperactivity, inattention, impulsivity, repeated bullying other children, stealing, lying, disobedience  Academic: • Started schooling at 3.5 years of age and education continued till BA. • Patient was an average student & didn’t get complaints from his teachers. PERSONAL HISTORY Dr. IMMANUEL JOSHUA (BHU) 16
  • 17.  Average built.  Conscious and co-operative for the examination.  BP- 134/84 mmHg  Pulse- 92 beats/min GENERAL PHYSICAL EXAMINATION  Afebrile  Weight-56kg  Height-168cm  BMI-19.84kg/m2  No PICCLE Dr. IMMANUEL JOSHUA (BHU) 17
  • 18.  No Abnormality Detected in examination of; • Cardio-Vascular System • Respiratory System • GI System (per abdomen) • Central Nervous System SYSTEMIC EXAMINATION Dr. IMMANUEL JOSHUA (BHU) 18
  • 19. 1. General Appearance and Behavior: • A young male of average built with normal gait & posture. • Face looks fatigued, dull and downward. • He was properly groomed & dressed. • Hygiene was adequate. • He was calm & co-operative throughout the interview • He was well oriented to time, place & person. • Eye to Eye contact established but not sustained. • He feels shy to answer questions. MENTAL STATUS EXAMINATION Dr. IMMANUEL JOSHUA (BHU) 19
  • 20.  2. Speech: • Non-spontaneous • Coherent • Relevant • Goal directed  3.1. Mood: “sad”  3.2. Affect: “sad” MENTAL STATUS EXAMINATION Quantity Rate Volume Tone Reaction Time decreased decreased decreased Normal Increased Dr. IMMANUEL JOSHUA (BHU) 20
  • 21.  4. Thought: • Stream : decreased flow • Form : NAD • Possession of thought : NAD • Content : Filled with complaints • Impression : Ideas of guilt  5. Perception: Hallucination or illusion could not be elicited MENTAL STATUS EXAMINATION Dr. IMMANUEL JOSHUA (BHU) 21
  • 22.  6. Cognitive Function: • Orientation: patient was oriented to time, place and person. • Attention & Concentration : Arousable and sustained. • Memory: Immediate, recent and remote memory are intact. • Intelligence: o Arithmetic: good skill (salesman) o Comprehension: intact • Adequate abstract thinking MENTAL STATUS EXAMINATION Dr. IMMANUEL JOSHUA (BHU) 22
  • 23.  7. Judgement: Patient behaviour in Personals ,Social & Test are intact  8. Insight: Present MENTAL STATUS EXAMINATION Dr. IMMANUEL JOSHUA (BHU) 23
  • 24. A young married male belonging to Hindu middle class nuclear family with no significant past psychiatric history and with Family H/O father having depressive disorder presented with following complaints with total duration of illness for 3-4 months. The complaints were acute in onset with continuous course characterised by decreased sleep, decreased appetite, sadness of mood, loss of interest, anhedonia, easy fatigability, ideas of guilt. Speech –Q/V/R decreased with increased RT Affect is sad restricted, Thought content suggestive of ideas of guilt Oriented to time/place/person, attention and concentration are arousable and sustained, memory intact, average intelligence, abstract thinking, judgement intact, Insight is present. CASE SUMMARY Dr. IMMANUEL JOSHUA (BHU) 24
  • 25.  Moderate depression PROVISIONAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS  Adjustment disorder with moderate depression Dr. IMMANUEL JOSHUA (BHU) 25
  • 26. • Evaluate the patient with some baseline investigations:  CBC  RBS  LFT  RFT  Serum electrolytes  Thyroid function test MANAGEMENT • Detailed general and systemic examination of the patient • HAM-D scale • Treatment:  T. ESCITALOPRAM (10mg /day)  T. CLONAZEPAM (0.5mg) HS Dr. IMMANUEL JOSHUA (BHU) 26
  • 27. • Psychoeducation to the patient and his family members • Address current psychosocial stressor or the relationship difficulties • Reactive social networks like family gathering ,outing with friends • Structure physical activity for 45 min/day for 3 times/week • Regular follow up in-person or by phone for re-assessing the improvement NON PHARMACOLOGICAL MANAGEMENT Dr. IMMANUEL JOSHUA (BHU) 27