Psychiatry III Case Conference 1 III-B Cueto, Mary Anne Carol – Diaz, Mark Fernan.
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Transcript of Psychiatry III Case Conference 1 III-B Cueto, Mary Anne Carol – Diaz, Mark Fernan.
Psychiatry IIICase Conference 1
III-B
Cueto, Mary Anne Carol – Diaz, Mark Fernan
General Data L.M.P
35 y/omarriedBorn Again Christian2nd in a brood of 3BS Nursing Graduateunemployedborn & raised in Capizadmitted 1st time on April 4, 2005
Informants: Patient: 75%Husband: 85%Sister: 85%
Chief Complaint: insomnia, delusion of reference According to patient: “ Pinaghihiwalay ang family
namin
ng ministry.”
According to husband: “ Hindi makatulog, minsan nagbabasa ng bible mag-isa”
“ Feeling nya pinagtutulungan siya ng
ministry”
Personality Profile:
Pre-morbid personality: “masinop, masayahin, sensitive”
Morbid personality: “tahimik, kung anu anong sinasabi”
History of Present Illness
2001 * very active, sings in the choir
2004 * negative feelings towards members and ministry
December
2005 * persistent negative feelings towards members and
January ministry, delusion of reference
2005 * auditory hallucination, loss of appetite, reduced
February sleep, negative feeling towards her husband
2005 * auditory hallucination, odd behavior, blank stares
1st wk March anxious
History of Present Illness
2005 * quiet, unresponsive
3rd wk March
2005 * verbal aggression, delusion of reference
March 25
2005 * felt guilty of what she said to the members,
March 26 delusion of persecution
2005 * neglected her chores and children, delusion
March 27 of persecution/anxiety
2005 * singing songs, speaking incomprehensible words
March 31
History of Present Illness
2005 * suspicious w/her surroundings
April 1 * brought to Las Pinas Doctors Hospital
* injected w/unrecalled medication
* admitted @ USTH while sedated
Review of Systems
(-) Headache, loss of consciousness, convulsions
(-) fever
(+) anorexia , weight loss
FAMILY HISTORY
(+) HPN – mother
(+) stroke – mother
(+) heart disease, PUD – father
(+) alcohol dependence – father
(?) nervous breakdown – great grandmother
PERSONAL HISTORY
Non-smoker
Non-alcoholic beverage drinker
Denies use of any prohibited drugs
ANAMNESIS
PRENATAL AND PERINATAL HISTORY
Born to 23 y/o G2P1 (1001); NSD at home
By traditional birth attendant
No prenatal or postnatal complications
Neuro-developmental milestones at par with age
EARLY-MIDDLE CHILDHOOD
Lived with parents and three siblings
Family owns a small grocery store
Left in the care of the father, an alcoholic
Father had occasional fights with his wife
Patient admits his father had his “weaknesses” but was very affectionate and loving
Patient grew-up closer to her father and siblings
MIDDLE CHILDHOOD
Primary education at Malubog-lubog Elementary School in Capiz
Average student and had very few friends
6th grade - father died which caused extreme sadness and felt that a big part of her was lost with the passing
Left in the care of the eldest sibling (Gina)
Gina confided of being overprotective of her younger siblings
ADOLESCENCE Family Relationship
after father’s death, mother married a policeman
Siblings were against the marriage at first
Patient felt that the mother betrayed her father
According to the patient, she had a harmonious relationship with stepfather and stepsiblings
Stepfather did not impose himself on the stepchildren was kind and approachable and was readily
approachable when they need him
ADOLESCENCE
Social Relationships
Claimed to have a number of friends
stayed at home on weekends because mother would not allow her to go out with friends
School History
Attended high school in FLAIMER Christian Institute in Capiz
Wanted to take up AB Philosophy
forced by mother to take up BS Nursing
Graduated on time
ADOLESCENCE
Academic Achievement
failed Nursing Board Exams (1990)
failure due to “poor preparation”
Worked as an assistant nurse in a small clinic while waiting for the next board exams
took the boards in Manila and passed with high marks (1992)
Did not work at once because she was waiting for her petition from her maternal aunt to work in Germany
After some time worked as a ticketing supervisor at Ever Gotesco Cinema
Resigned after 2 months, thinking she was not ready to work yet
Learned that her petition was declined
YOUNG ADULTHOOD
1993 - nurse in Capiz and resigned after 6 months
Felt bad in an incident when a patient deteriorated infront of her
According to sister: Patient was pious and hardworking
Gave portion of salary to patients
YOUNG ADULTHOOD
1994- went back to Manila and stayed with sister
Meaningful Long-term Relationship
met Norman and married him after two years (1996)
- Stayed with husband’s family (Cavite)
After a few months, husband flew to Abu Dhabi
Patient got pregnant and went back to Capiz
Had difficult pregnancy
- 1997 – CSD with her 1st child (Paul Christian)
YOUNG ADULTHOOD
1998 – went to Abu Dhabi with husband and had no difficulty in adjusting
Worked as sales clerk in a pharmacy
December 1999 – decided to return to Philippines due to 2nd pregnancy
2000 – gave birth to second child (Patricia Lois)
Stayed with her mother, who sometimes helped out with her grandchildren
Longed for her husband
YOUNG ADULTHOOD
2001 – returned to UAE with her children because of argument with mother
Was baptized to a ALL Nations FULL GOSPEL, a Born Again Christian group
Planned to work as a nurse however got pregnant with her 3rd child
YOUNG ADULTHOOD
First worked as an assistant nurse
Very little compensation while waiting for the next board exams
resigned to take 2nd board exam
Worked as Ticketing supervisor and resigned after 2 mos
Petition by her maternal aunt was declined by the German Embassy
1998 - sales clerk in a pharmacy in Abu Dhabi
1999 - resigned because of 2nd pregnancy
No difficulty adapting to new environment
No difficulty adjusting to new role as mother
WORK EXPERIENCE
FAMILY PROFILE
Cesar- father
Died of “heart attack” at 45
An elementary graduate
Came from a well off family in Capiz
Alcoholic since 20 y/o Drank gin (? amount) almost everyday usually alone
or with friends
Patient regards him as loving and kind father
Patient claims she got her talent from him He usually sang with her
Minerva- mother
58 y/o, elementary graduate
Strict disciplinarian in the family
Managed mini-grocery store with Cesar
Patient would have arguments with her
FAMILY PROFILE
Ricardo Delfin – stepfather
60 y/o, retired policeman
Treated his stepchildren as his own
Takes care of Minerva very well
FAMILY PROFILE
Gina – sister
38 y/o, BS Music undergraduate
Married, currently unemployed
Previously worked as a singer in Japan
Currently lives with husband and 5 children in Caloocan
Very close to the patient; patient’s confidant
FAMILY PROFILE
Julius- brother
33 y/o, college undergraduate
Married with 2 children
Previously worked as a seafarer
Stays at Panitan, Capiz with their mother
Suffered stroke
Small business – selling prepaid cards
FAMILY PROFILE
Norman- husband
38 y/o, aeronautics graduate
Trainer at Estilat Telecom Co. in UAE
Member of ALL Nations FULL GOSPEL for 10 years
Very loving and supportive husband and father
FAMILY PROFILE
Paul Christian – son
8 y/o, Grade 2 student
Good relationship with parents and siblings
Has problems in school Hyperactive and lazy to copy notes
FAMILY PROFILE
Patricia Lois – daughter
5 y/o, Kinder II student
Very bright daughter
Consistent honor student
Has good relationship with parents and siblings
FAMILY PROFILE
Tim Albert- son
2 y/o
FAMILY PROFILE
Tim Albert2
Cesar45
Gina38
Paul Christian
8
Patricia Lois
5
L35
Norman38
1996
Minerva58
4
LEGEND Heart attack
Stroke
PUD
HPN
Ricardo Delfin
60
Julius33
5 2
Physical Examination
essentially normal
Neurological Examination
essentially normal
Mental Status Examination
Looks appropriate for age
Kept wearing pink blouse and black slacks
Cooperative with good eye contact, answers appropriately
No mannerisms and psychomotor agitation noted
Euthymic mood with appropriate affect
Claims that she has “discerning spirit” & the ministry is against her
Conscious, oriented to time, place and person
Memory is intact with good attention span
Fair judgment and impulse control and poor insight
Salient Features
35 y/o
Female
Born again Christian
Unemployed
Preoccupation with at least 2 delusions (Jan-March2005)
Auditory hallucination
Aggressive/agitated behavior (March 2005)
Avolition-apathy (3rd wk & 27 Mar)
Salient Features
Incomprehensible speech
Impaired social functioning
Physiologic disturbance: anorexia and insomnia
Family history: great grandmother had nervous breakdown
Non-smoker, non-alcoholic, denies use of prohibited drugs
Poor relation with mother
Normal physical and neurologic exam
Unremarkable general appearance , behaviour and psychomotor activty
Euthymic mood with appropriate affect
(+) Hallucinations & delusions
Conscious, oriented, good memory and attention span
Fair judgment and impulse control
Poor insight
Salient Features
DIFFERENTIAL DIAGNOSIS
Major Depressive Disorder
Bipolar Disorder
Schizophrenia
DSM-IV-TR Diagnostic Criteria for Major Depressive Episode
A. FIVE (OR MORE) OF THE FOLLOWING SYMPTOMS HAVE BEEN PRESENT DURING THE SAME 2-WEEK PERIOD AND REPRESENT A CHANGE FROM PREVIOUS FUNCTIONING; AT LEAST ONE OF THE SYMPTOMS IS EITHER (1) DEPRESSED MOOD OR (2) LOSS OF INTEREST OR PLEASURE. NOTE: DO NOT INCLUDE SYMPTOMS THAT ARE CLEARLY DUE TO A GENERAL MEDICAL CONDITION, OR MOOD-INCONGRUENT DELUSIONS OR HALLUCINATIONS. 1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. THE SYMPTOMS DO NOT MEET CRITERIA FOR A MIXED EPISODE.
C. THE SYMPTOMS CAUSE CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN SOCIAL, OCCUPATIONAL, OR OTHER IMPORTANT AREAS OF FUNCTIONING.
D. THE SYMPTOMS ARE NOT DUE TO THE DIRECT PHYSIOLOGICAL EFFECTS OF A SUBSTANCE (E.G., A DRUG OF ABUSE, A MEDICATION) OR A GENERAL MEDICAL CONDITION (E.G., HYPOTHYROIDISM).
E. THE SYMPTOMS ARE NOT BETTER ACCOUNTED FOR BY BEREAVEMENT, I.E., AFTER THE LOSS OF A LOVED ONE, THE SYMPTOMS PERSIST FOR LONGER THAN 2 MONTHS OR ARE CHARACTERIZED BY MARKED FUNCTIONAL IMPAIRMENT, MORBID PREOCCUPATION WITH WORTHLESSNESS, SUICIDAL IDEATION, PSYCHOTIC SYMPTOMS, OR PSYCHOMOTOR RETARDATION.
DSM-IV-TR Diagnostic Criteria for Manic
Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a Mixed Episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).
DSM-IV-TR Diagnostic Criteria for Hypomanic
Episode
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. CHARACTERISTIC SYMPTOMS: TWO OR MORE OF THE FOLLOWING, EACH PRESENT FOR A SIGNIFICANT PORTION OF TIME DURING A ONE-MONTH PERIOD (OR LESS IF SUCCESFULLY TREATED)1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly Disorganized or Catatonic Behavior
5. Negative Symptoms
B. SOCIAL/OCCUPATIONAL DYSFUNCTION
C. DURATION:continous signs for atleast 6 months that must include:
1 month of active symptoms (or < if succesfully treated)± periods of prodromal or residual symptoms
•only negative symptoms•2 or more Criteria A symptoms in attenuated form (eg. Odd beliefs, unusual perceptual experience
D.SCHIZOAFFECTIVE DISORDER EXCLUSION
E. SUBSTANCE/ GENERAL MEDICAL CONDITION EXCLUSION
F. RELATIONSHIP TO A PERVASIVE DISORDER
DSM-IV-TR Diagnostic Criteria for Schizophrenia Subtypes
PARANOID TYPE
A.PREOCCUPATION WITH ONE OR MORE DELUSIONS OR FRQUENT HALLUCINATIONS
B. NO DISORGANIZED SPEECH, DISORGANIZED OR CATATONIC BEHAVIOR, FLAT OR INAPPROPRIATE AFFECT
DISORGANIZED TYPE
A. ALL OF THE FOLLOWING ARE PROMINENT:
1. Disorganized Speech
2. Disorganized Behavior
3. Flat or Inappropriate Affect
B. THE CRITERIA ARE NOT MET FOR CATATONIC TYPE
CATATONIC TYPE
A type of schizophrenia in which the clinical picture is dominated by at least two of the following:
1. Motoric immobility as evidenced by catalepsy or stupor
2. Excessive motor activity
3. Extreme negativism
4. Peculiarities of voluntary movement as evidenced by posturing, stereotypied movements, prominent mannerisms, prominent grimacing
5. Echolalia or echopraxia
UNDIFFERENTIATED TYPE
A type of schizophrenia in which symptoms meet Criterion A present, but the criteria are not met for the paranoid, disorganized, or catatonic type
RESIDUAL TYPE
A.Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized speech and grossly disorganized, or catatonic behaviorB. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms listed in Criterion A for schizophrenia present in attenuated from