The document presents a case of Mohamed A. Abdel Khaleq, a 40-year-old male with a long history of cannabis use and severe psychiatric symptoms including aggression, delusions, and hallucinations. He has faced repeated episodes over 12 years, with recent complications arising from non-compliance with treatment and recurring convictions of being targeted by external forces. The provisional diagnosis suggests bipolar affective disorder with psychotic features, and the management plan includes hospitalization, pharmacotherapy, cognitive behavioral therapy, and family psychoeducation.

1. Case Presentation
Prof.Dr.Hisham Ramy
clinical round
Resident : Ahmed Samir

2. About the patient
1.
P.Data, Referral and
complaint
Discussion
2.
History and examination
Diagnosis
3.
Provisional and DD
Management
4.
Investigation and
treatment
Patient follow-up
5.
Outpatient arrangement
Table Of Contents

3. Personal Data
Mohamed A. Abdel Khaleq, a 40 year-old male
patient, born on 13/10/1984 , obtained certificate of
preparatory school, used to work before as a truck
driver and ‫فراشة‬ ‫صنايعي‬, ‫سجاد‬ ‫مغسلة‬ ‫في‬ ‫عامل‬,
unemployed for 2 years
single ,lives in 15
‫القاهرة‬ ‫ـ‬ ‫األميرية‬ ‫ـ‬ ‫خليل‬ ‫مرسي‬ ‫عزبة‬ ‫الجامع‬ ‫ش‬
Rt handed, Smoker, with a long history of
Cannabinoid use, no other special habits of medical
importance.

4. Source of Referral
His brother Ahmed & mother
(Involuntary admission)
Cause of Referral
Physical aggression and violence
against family and bystanders in
street, using a knife .
D.O.A
01/02/2024
It’s the 2nd admission for him

5. THE INFORMANT (his brother ; reliable)
THE PATIENT
‫لنا‬ ‫وعامل‬ ‫أمه‬ ‫بيشتم‬
‫مشاكل‬
‫في‬ ‫الناس‬ ‫مع‬
‫الشارع‬
‫الشرطة‬ ‫ومع‬
..
‫ورفع‬
‫البيت‬ ‫في‬ ‫السكاكين‬ ‫علينا‬
..
‫جيبه‬ ‫في‬ ‫بسكينة‬ ‫ماشي‬ ‫شهر‬ ‫وآخر‬
‫طول‬ ‫ع‬
.
‫أ‬
‫نا‬
‫المستشفى‬ ‫أروح‬ ‫إما‬ ‫يا‬ ‫السجن‬ ‫في‬ ‫يتقتل‬ ‫أخويا‬ ‫إن‬ ‫بين‬ ‫متهدد‬
..
‫عني‬ ‫غصب‬ ‫فجيت‬
.
Complaint

6. Present Hx
The condition started 12 years ago with gradual onset , episodic course with
increasing deficit, after significant increase in hash smoking : 6-8 cigarettes
per day , patient started to have decreased need for sleep , in addition to
being more talkative than before with increased irritability and motor activity
followed by being convinced that his mother wanted to kill him by putting
poison in his food , so he refused to eat or drink at home and lost weight ,
was shouting at his mother and insulting her , then he became violent ,
talking to himself , wandering in the streets , neglecting his hygiene and
grooming , then he was convinced that his uncles and neighbours are spies
for the sake of Israel and went to the Egyptian Intelligence building more
than one time to tell them and to work with them . And they were letting him
go.
He was also convinced that someone did magic to harm him.

7. His family sought help from traditional and religious healers, they advised his
family to seek medical help .
They took him to a private psychiatrist who prescribed ttt , patient took them
reluctantly and showed partial improvement (all except some false beliefs
persisted) for 1 month. Then, he became incompliant with period of complete
cessation of medication for years with recurrence of episodes and partial
compliance with significant deficit at his work functioning ,,,
‫سجاد‬ ‫مغسلة‬ ‫في‬ ‫عامل‬ ‫يشتغل‬ ‫وراح‬ ‫عنده‬ ‫اللي‬ ‫والفراشة‬ ‫السواقة‬ ‫ساب‬.
At 2020 , the same features of illness flared up again with the same false
beliefs and was admitted at Al Khanka hospital for 45 days , received 9 ECT
sessions, medications: halonace , depakine , neurazine and prianil which
aggravated psoriasis. With improvement ,

8. Present Hx
Along the last year , the same features of illness recurred .. but the false beliefs
started to be more disorganized . He refused to see a psychiatrist again , started by
decreased need for sleep , significant hyperactivity , self neglect ..He is convinced
that the magician of Hosny Mubarak did magic to him to enable him to hear ( the
Qareen ) of all people , he shouts loudly at people from balcony claiming that he hears
their qareen and responds to them as a human , self talking , talking more than usual,
telling that all people of his village are spies for the sake of Israel ,
‫ده‬ ‫ينسوه‬ ‫عشان‬ ‫العقل‬ ‫ضلع‬ ‫منه‬ ‫خدوا‬ ‫أخواله‬
..
Then he was compliant on ttt for the following two years , with complete relief of false
beliefs and illness features , following up with a private psychiatrist , one year and a
half of them with no Hash smoking … started to smoke HASH again , his doctor
decreased his drugs ,,, was only on injections monthly for 4 months , then
discontinued treatment

9. He went again to the Egyptian intelligence building asking for his financial dues (2
millions) and his military suit as Mubarak asked him at 2004-2006 to guard all the
mosques of the world including makka , madina , quds al aqdas,& ‫االستواء‬ ‫خط‬
‫بيكلموني‬
‫أروح‬ ‫عايز‬ ‫مش‬ ‫وأنا‬ ‫آجي‬ ‫عايزني‬ ‫المكي‬ ‫الحرم‬ ‫في‬
‫السجن‬ ‫في‬ ‫اللي‬ ‫أخونا‬ ‫يقتل‬ ‫عاوز‬ ‫الموساد‬ ‫ان‬ ‫عندك‬ ‫اللي‬ ‫للناس‬ ‫قول‬ ‫له‬ ‫بيقول‬ ‫السعودية‬ ‫في‬ ‫اللي‬ ‫أخوه‬ ‫كلم‬
‫العالم‬ ‫على‬ ‫وارميها‬ ‫الهيدروجينية‬ ‫القنبلة‬ ‫صنع‬ ‫لي‬ ‫قال‬ ‫بوتين‬ ‫بيقول‬
‫الناس‬ ‫بيه‬ ‫أفكر‬ ‫عهد‬ ‫مديني‬ ‫ربنا‬
‫عليها‬ ‫ويقبضوا‬ ‫ودوالرات‬ ‫دهب‬ ‫فيها‬ ‫اللي‬ ‫زامبيا‬ ‫بتاع‬ ‫الطيارة‬ ‫تستنى‬ ‫المصرية‬ ‫القنصلية‬ ‫بلغت‬ ‫اللي‬ ‫أنا‬
‫سايب‬
‫فيديوهات‬
‫فيها‬
‫معلومات‬
‫سرية‬
‫مع‬
‫اصحابي‬
‫لو‬
‫اتاخرت‬
‫هنا‬
‫هينشروها‬

10. +ve long Hx of
Hash abuse
since 2008
No other
psychiatric
diseases
Single previous
admission at Al-
khanka hospital at
2020
Previous hx of receiving
psychiatric medications
and ECT
No Hx of self harm
Past Psychiatric Hx

11. Substance Hx
Cigarettes
01
Hash
02
The informant and the patient denied
any other substance use
03
Started smoking regular cigarettes
1-2 cig/day at age of 16 under
friends influence till reached
maximum of 60 Cig/day
Started using cannabis at 2008 ,
1 cig/ day at age of 24 ,increased reaching
8-10 cig/day at 2012 ,
Current use 1-2 cig/day … last cigarette was
just before his admission

12. Past medical & Surgical HX
Medical
Diagnosed with
Psoriasis since
2000 , compliant on
ttt during attacks
only
No surigical Hx
No Hx of head
trauma or
accidents

13. Family history
● Consanguinity: -ve
● Birth Order: 2nd
● Father: Ahmed Abdel Khaleq , 70 y.o with Psoriasis & treated from HCV
worked as a truck driver, now retired and his parenting style was
authoritarian and has quarrelsome relationship with the patient.
● Mother: Soad Mohamed Altoukhy, 62 y.o ,Diabetic and hyprertensive,
a housewife and her parenting style was permissive and has a harmonious
relationship with the patient.

14. Family history
● Crowding index: 2/room.
● Family Income: Adequate and regular.
● There is no family history of similar condition
● There is no family history of other psychiatric disorders.
● There is a family history of Diabetes , Hypertension and Psoriasis
Sibling name Amr Karim Ahmed
Age 42 , married 36 , single 29, single
Education ‫وفنادق‬ ‫سياحة‬ ‫معهد‬ ‫دبلوم‬ ‫دبلوم‬
Work Hotel manager
at Saudi Arabia
Imprisoned ,
arrested by
drugs
Transport driver
at Saudi Arabia
Relationship
with the patient
Harmonious Harmonious Harmonious

15. Personal
History

16. Perinatal & developmental Hx
Prenatal & natal 01
Developmental 02
Neurotic
symptoms 03
Passed uneventful
full term, vaginal delivery , breastfed
Uneventful with normal milestones (Social,
motor, speech, sphincters)
Social child with temper,
Built bad influenced
friendships,
No childhood illness with medical importance was reported

17. Education & Work Hx
Education
Claimed good
relationship with
classmates and
teachers
Started at age of 6,
Had friends, low
achievements
Left education after
3rd preparatory school
Work, military and
forensic
Worked as truck driver
and ‫فراشة‬ ‫صنايعي‬ till 2015 ,,
then ‫سجاد‬ ‫مغسلة‬ ‫في‬ ‫عامل‬
Exemption from military
service due to ????
Hx of legal problems,
arrests. ??????

18. Sexual Hx
Patient reached puberty at the age of
15 with gender identity aligns with
gender at birth, male gender
expression and role, heterosexual
orientation and fantasias.
not sexually active, previous
engagement was made at 2007 ,
ended by break up

19. Premorbid Personality
Extrovert with many friends,
sociable, with playing football and
watching TV as hobbies
Believer, irregular practitioner
React to stress by temper and
bouts of anger mostly
Emotionally stable

20. Examination
● Physical Examination:
● Temp: 37
● Pulse: 90
● BP: 110/80
● There is no pallor or cyanosis or jaundice, no injuries or injections marks.
● Nervous System: NAD
● CVS: NAD
● Respiratory System: NAD
● GIT: NAD

21. Mental State Examination
Male, Corresponds to his chronological age, average height but thin, fair hygiene and
grooming, calm, cooperative, fair eye to eye contact, no postural abnormalities
Conscious, OTPP, average attention, poor concentration and intact memory
euthymic mood with restricted affect
Spontaneous , incoherent, pressured , increased quantity .. Monotonous high volume and
rate

22. auditory hallucinations
Insightless , Judgment is impaired
Stream : very rapid with flight of ideas
Process : formal thought disorder loss of association ,
circumstantiality ,Tangentiality , derailment
Content : Delusion of grandiosity and persecution . no
current ideas of suicide or homicide.
Abstract thinking
thought withdrawal
‫أهل‬
‫العزبة‬
‫كاملة‬
‫بيسرقوا‬
‫أفكاري‬

23. A 40 -year-old single adult male patient, single , smoker, currently
unemployed with Hx of Hash abuse , presented for his 2nd admission
11 days ago with gradual onset and episodic course of 12 years
duration of deterioration functionally in the form of verbal and physical
aggression, dangerous behavior, unstable mood, spontaneously
induced pressured incoherent speech along with bizarre delusions of
grandiosity and persecution as well as auditory hallucinations with
formal thought disorders .
All through Hx, no depressive, OCD or anxiety symptoms were
reported and no symptoms suggestive of other systems involvement.
Case Formulation

24. Biological Psychological Social
Predisposing
Genetics
Substance abuse2008
Break up of his single
engagement ,
Eaducational
discontinuation
Precipitating
Substance abuse
Highly Increased
dose
Perpetuating
Non compliance
Substance abuse
Unemployment
single
Protecting Supporting brothers
Formulation ( Dynamic )

25. Differential Diagnosis
Bipolar affective disorder
manic episode with
psychotic features
(Provisional Dx)
Schizoaffectiv
e disorder
Substance
Induced
Psychosis
Schizophrenia

26. Management
RBS, CBC, CRP, LFT, RFT, TFT,
toxicology screen (+ve cannabis)
Routine Lab
Further
information
Psychometry
EPQ-R
MMPI
1- Investigations

27. 2- Treatment
Hospitalization
Management
ECT

28. Psychpharmacology
Halonace 5 mg oral tablets 1 X 3
Depakine chrono 500 mg 1 X 2
Neurazine 100 mg 1 X 1
Achneton 2 mg 1 X 1
After 1 week
+ Haloperidol Retard 50 mg amp 2 / month

29. Psychotherapy
CBT for psychosis
Motivational therapy
Rehabilitation
Psychoeducation to the family and the patient
Occupational therapy

30. THANK YOU !