1. NG BOON KEAT MOHD HANAFI PSYCHOLOGICAL MEDICINE CONFERENCE
2. MR. S 55-year-old | Security Guard Married | 3 children Progressively worsened disturbed behaviourfor 4 days
3. HISTORY OF PRESENT ILLNESS Brought by the son to the accident and emergency due to bizarre behaviours: Appeared to be irritable and aggressive Shouting with vulgar words No physical damages to self or other people Known case of psychiatric illness, under UMMC follow-up
4. WITHIN 3 DAYS Decrease need for sleep Increase activities Wandering around the house non-stop Pacing faster than normal Talkative Described as talking non-sense Impaired functions Cannot do daily activities properly Getting complains from working colleagues Mood is happy without reason
5. FURTHER CURRENT HISTORY No psychotic symptoms No depressive symptoms Clear history of past depressive episodes
7. PAST PSYCHIATRIC HISTORY Since 2002 Multiple admission due to inappropriate behavior with depression. Treated with: Lorazepam| anxiolytic Chlopromazine | antipsychotic Perphenazine | antipsychotic Carbamazepine | anxiolytic Poor compliance to medication
8. PAST PSYCHIATRIC HISTORY 8/02 Sm: Abnormal behaviour & Epilepsy SurgDx: AVM 1/06, 7/06, 12/06 Multiple admission on Epilepsy 10/09 Motor Vehicle accident: cross the highway |polytrauma[contusion, haemothorax, SDH, AVM Current Admission 2005 2006 2007 2008 2009 2010 12/05 Sm: ↓ need of sleep, aggressive [shouting] 19/8 – 21/9 Stressor: stolen motor, Fired from job Sm: shouting to family, aggitated 10/09 After operation: ruptured diagphragm with right upper limb fracture
9. PAST MEDICAL HISTORY Known case of epilepsy since young. Patient was seeking psychiatric service in UMMC in 2002 and was referred to surgical team the same year.
10. Diagnosed to have arteriovenous malformation. Healthy without other medical conditions. No previous history of ECT: AVM Epilepsy
12. FAMILY HISTORY d. | unknown cause 70 | housewife | no medical illness No psychiatric, suicide history in the family No history of epilepsy, neurological disease in the family. Family relationships are good.
13. PERSONAL HISTORY: EARLY CHILDHOOD 13/4/1955 | AlorStar uncomplicated FTSVD | village midwife. No health problems| Nodevelopmental delay
14. PERSONAL HISTORY: SCHOOL PERFORMANCE SRK Kancut| SMK Syed Omar Moderate achievement in primary school Drop-out of school after SRP due to poor performance No disciplinary problem Socialize with friends
15. PERSONAL HISTORY: WORK RECORDS Move to Kuala Lumpur | 18-year-old Work | security guard since then. Never change his job. Income | around RM1000
16. PERSONAL HISTORY: SEXUAL ATTITUDE AND PRACTICE Nosexual experience | before marriage 1st intercourse |age of 30 No history of child abuse
17. PERSONAL HISTORY: MARRIAGE Arrangedby parents His wife: 53 year old | Freelance teacher| Had been supportive to the husband despite his condition
19. PERSONAL HISTORY: SOCIO-CULTURAL BACKGROUND RM5000 family income per month?? Socialize with friends? No criminal records $
20. PERSONAL HISTORY: SUBSTANCE USE Smoking| 74 pack years No alcohol consumption | No substance abuse
21. PERSONAL HISTORY: PRE-MORBID PERSONALITY Proper social | relationships Stable mood |but depress occasionally Personality trait?? Weak faith | religion Favouritepast time | sports Coping skill | sports
22. MENTAL STATE: GENERAL APPEARANCE Alert | conscious | cooperative Easily make rapport | poor eye contact Hospital attire | unhygienic Anxious | frowning of the forehead
23. MENTAL STATE: SPEECH & THOUGHT ↑ amount | ↑ tone | ↑ rate Pressured speech Malay-spoken | coherence but irrelevance thought blocking | flight of ideas NO Loose/clang association | circumstantialities | neologism | obsession/phobua | delusions Suicidal thought
25. MENTAL STATE: COGNITIVE FUNCTION Time, Place, Person | Orientated Remote, Recent Memory | Good [date of birth & breakfast] 5mins memory test | Remember only 1 Information/knowledge | Appropriate Proverbs | Can answer [Udang di sebalikbatu & sikit-sikit lama-lama jadibukit] Similarities | Give 2 [apple & orange: tastes, eaten]
26. MENTAL STATE: COGNITIVE FUNCTION 2 Attention | Easily distracted Concentration | Cant do it [serial 7 test, digit span, world backward] Judgement | Cant assess [patient started irritable and agitated] Insight | Poor [he and others do not realised his abnormality | not accept and do not need treatment]
27. PHYSICAL EXAMINATION Alert | conscious | not in respiratory distress. 37.5˚C | 92 beats pm | 20 bpm| 120/80. Couldn’t assess 1st day | patient irritable and agitated 2nd day | patient physically restrained and chemically sedated
28. IN SUMMARY History| irritable, aggressive and shouting for 4 days, with maniac symptoms | no depressive symptoms within the current period Previous History | psychiatric illness since 2002 | not complicant with medication | Complicated with AVM and MVA Mental State | easilydistracted | mostly cannot assess| poorinsight
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31. WHAT IS THE MOST LIKELY PROVISIONAL DIAGNOSIS?
32. PROVISIONAL DIAGNOSIS BIPOLAR I DISORDER manic episode The patient has had at least one previous major depressive episode, manic episode, or mixed episode
39. MANAGEMENT IN THE WARD | Psychiatric View | Psychotic medication not aim to cure the organic condition ECT cancelled Given Rozidal, Carbamazepine, Lorazepam, Chlorphomazine
40. MANAGEMENT IN THE WARD | Neurosurgical View | CT Brain done Cerebral oedema and complex AVM No surgical management available (grade 5 AVM)
43. MANIA AND FRONTAL LOBE Secondary mania can be resulted from frontal lobe lesion Multiple case studies reported that most mania symptoms occurs in RIGHT frontal lobe lesion. Can occur immediately or later in life after injury.
49. AVM: TREATMENT Surgerynot a chance Vascular surgery not a chance Radiosurgery only chance for the patient(do in stages)
50. DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary mania) Elation or irritability Four of the following: inflated self-esteem or grandiosity decreased need for sleep pressured speech flight of ideas Distractibility increased goal-directed activity or psychomotor agitation excessive involvement in pleasurable activities
51. ORGANIC MOOD DISORDER: CLASSIFICATION ICD-10 specifies that the affective disorder must be judged not to represent an emotional response to the patient’s knowledge of having a concurrent brain disorder.
53. ORGANIC MOOD DISORDER: EPIDEMIOLOGY Depression in the medically ill appears to be equally prevalent by sex, or possibly slightly higher in men (Caine and Lyness, 2000). Patients with secondary mania are more likely to have negative family and personal histories of mood disorder (Evans et al., 1995)
55. ORGANIC MOOD DISORDER: MANAGEMENT Poststroke Depression Nortriptylineand trazodone. (Lipsey et al., 1984; Reding et al., 1986). Traumatic Brain Injury Depression Desipramineand sertraline (Wroblewski et al., 1996; Fann et al., 2000). Manic Lithium (Evans et al., 1995). SecondaryMania Clonidine, valproate, carbamazepine and antipsychotics (Bakchine et al., 1989; Starkstein et al., 1991)
Editor's Notes
Unhyeginiec – urine smell/split his sputum on the floor
Flight of ideas – Taman medan Taman DesaRia Bangunan tinggi2
Investigation?????????
Secondary mania closed head injury, and relatively frequent occurrence of irritability, aggression and hypersexuality has important implications for management of these patients. The major neuroanatomic correlate of mania after TBI is the presence of anterior temporal lesions (Robinson et al., 2000). Infectious processes, including HIV infection, may also be an important risk factor for the development of secondary mania, and it has been suggested that mania occurring late in HIV infection is likely the result of HIV effects on the CNS, while mania that occurs early in asymptomatic HIV seropositive patients may be more etiologically related to genetic predisposition (Evans et al., 1995).
