Case presentation

Supervised by: Prof. Elham AlJammas

Presented by:

Esra Hazem Hayawi & Saja M. Alneimy

General knowledges

Mr. M. W. E.

32 years old

Hay Aljammeaa

Muslim

Male

Single

Backer

D.O.A. : 1\12\2012

D.O.E. : 5\12\2012

Informant : the patient

Main complaint

He cannot sleep without using drugs since 2 years

History Of present illness

The condition started before 2 years after a surgical treatment for pilonidal sinus, for which he was given tramadol as sedative & pain killer drug by his doctor, in a dose of 50 mg tablet daily (on need) , to start with , after that he started to add another tablet every 2 or 3 weeks ,, until he reached 10 tablets per day ( 500 mg ) ,, he gets it without prescription , from his friend ( pharmacist ) .

He cannot sleep without tramadol , he didn’t know that this is an addicting drug .

All his family didn’t know about his condition till now , it was not preceded by any psychological problem nor associated with psychological complications during the first 6 months after surgery.

He became very anxious and can’t sleep even with all

these tablets After his marriage proposal was rejected by

the father of his girl friend , accordingly he consulted his

pharmacist’s friend , who added one tablets of valium 5

mg to start with , in addition to the tramadol , the dose of

the valium increased until it reach 8 tablets ( 40 mg ) per

day in addition to the (500 mg ) of tramadole daily,

the patient is heavy smoker 2 packets per day ,,

he is social alcohol drinker (as he said just three times

only )

His appetite was poor, always fatigue & angry .

Family history

his father is dead ( 7 years ago ) due to CVA , his mother

is alive & quite healthy

he has 2 brothers & 2 sisters all are married and healthy ,

Personal history

He was born in Mosul at 1\9\1980

he was healthy child , without nervous habits like nail

biting or sleep walking .

he was more attached to his mother because his father

use to beat him up & did not give him any present or buy

him any clothes.

School life:

He was rejected from school at sixth primary class after

being hostile toward his teacher ( بوكسات 3ضرب المعلم )

occupational record:

He works with his brother ( baker shop )

Past history

physical illness: He had a physical trauma when he was 7

years old child after falling on the floor and his right wrist

was injured .

surgical operation: For pilonidal sinus 2 years ago

pre morbid personality :

He was socially active, love his family and his friends

he was optimistic but sensitive and hostile towards his

teachers and peers .

Spend his leisure time playing video games,

General examination :

Conscious , sitting on bed , he looks ill but tidy & quiet ,

no tattooing , hyper aroused , no signs of anemia , & no

signs of jaundice nor signs of cyanosis.

vital signs

temp: 37 C

resp. rate:15 breaths \ min

pulse: 103 beats \ min

Blood Pressure:120\ 80 mmHg

Cardiovascular – Tachycardia , no murmur

Respiratory – normal resp. rate , no cyanosis

Gastrointestinal – poor appetite , no abnormal bowel

motion , no malena , no hematamesis

Neurological – fine tremor, no ataxia , no dyskinesia ,

normal deep tendon reflex.

Mental state examination:

Appearance : looks ill , but aggressive , poor eye to eye

contact

Talk : slow stream of speech, with poor content, but

relevant and coherent

Mood: he said he was happy and looks so, no suicidal

ideas.

Denies hallucination or delusion .

intellectual function :

- orientation , intact- time place and person.

- attention& concentration : normal

- memory is intact: immediate, recent , short and long

memory .

Intelligence: average IQ

general knowledge : Good

insight & judgment: also intact

Laboratory studies

CBC : RBCs 5.85*10^6\ul

HB 16.5 g\dl

HCT 52.2 %

MCV 89.3 fL

MCH 28.2 pg

MCHC 31.6 d\dl

PLT 192*10^3\ul

ESR 3 ml\hr.

Polycythemia

WBCs 8.32*10^3\uL

Neu. 5.20 62.5%

Lym. 2.28 27.4%

Mono. 0.583 7.01%

Eos. 0.192 2.31%

Baso. 0.065 0.780%

Blood Suger fasting : 5.6 mmol\L

Blood urea : 3.1 mmol\L

S. creatinine: 45 mmol\L

S.A.L.T. : 7 mmol\L

ECG

Differential Diagnoses

Alcohol-Related Syndromes

Amphetamine-Related Psychiatric Disorders

Anxiety Disorders

Cerebellar Disease

CNS Structural or Degenerative Disorders

Cocaine-Related Psychiatric Disorders

Delirium Tremens

Electrolyte Disorders

Endocrine Disorders

Hyperthyroidism

Metabolic Disorders

Mood Disorders

Pheochromocytoma

Schizophrenia

Seizure Disorders

Thyrotoxicosis

Toxicity, Anticholinergic

Toxicity, Sympathomimetic

Vasculitic or Infectious Disorders

Diagnosis :

Personality disorder

Drug addict (tramadol and valium ,alcohol,nicotine)

Treatment

Librium 5 mg 1x3

Tegretol 200 mg 1x3

placil 5 mg 1x3

ponstan 1x3

Thank you