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Intern Rotation End Test

Microteaching: Resident as a teacher : PG CME , Mumbai 13 December 2015

Case Based Learning: PG CME Mumbai 13 December 2015

Go over the clinical case to come to a conclusion about diagnosis and management

CASE 1

Case:

Mr. A, 36yr, male, divorced, 11th, unemployed

Chief complaints and duration:

1. Odd repetitive thoughts – since around 1990
2. Odd behavior, belief that he has great powers and is a great person – since end 2005

History of presenting illness: Apparently well prior to 1990, when he began to have obsessive impulses and images. During the same period voiced referential ideas, and started having difficulty in concentration and would at times speak odd things without conveying clear meaning. He failed in class 8th. These symptoms continued for till 1996, when he was started on T. Clomipramine 100mg/day, with which he had 50-60% improvement in his symptoms. After this, he did not pursue any meaningful activity or seek employment, stayed at home, would interact minimally with others along with continuation of the above described symptoms till about 2004.

In 2005, on one occasion, while randomly flipping through a book on computers, he saw the words “my shortcut button 238”. At that very moment, he reportedly realized that the message was specially for him and that it means, without doubt that he was a “maha purush” and has the button to a special computer that was created by him, through which he can control every person, the past, future and the present.  Following this would frequently voice grandiose delusions which were not associated with cheerfulness or increased activity levels. Along with grandiose delusions he would also frequently report auditory hallucinations. During the same period started hoarding trash and his self care also deteriorated. His obsessive symptoms reduced with the emergence of these symptoms. These symptoms have more or less has continued since then. He was married in 2009, but wife left him after few days of marriage, he didn’t show any concern for the same. During the period of 2006 to 2014, received adequate trials of risperidone (4-8 mg/day), olanzapine (10-20 mg/day), Olanzapine 10 mg/day along with Haloperidol 10 mg/day but did not perceive much benefit.

In Jan 2015, he once again began to have obsessive impulses while receiving T. Olanzapine 10mg/day and T. Haloperidol 10mg/day along with other previous symptoms. Following this, T. haloperidol was increased to 15mg/d, T. olanzapine was tapered and stopped and C. fluoxetine 20 mg/day started in July 2015, and increased to 40mg/d in Aug 2015. However, despite good compliance, there was no improvement in psychotic and obsessive symptoms, and hence was admitted for management.

Past history: Not significant.

Family history: Mother and 2 brothers – diagnosed to have OCD. On clomipramine

Personal history: Impaired relationship with wife due to illness

Premorbid temperament: inadequate information

Physical examination: No P/I/C/C/L/E   Systemic examination was normal WC99kg , BP-140/80mmHg, BMI-29.3kg/m2,

Mental status examination: Flat/blunted affect, derailment, delusion of grandiose identity and power, obsessive impulse, image and rumination, impaired attention concentration and memory, poor insight

Instructions for students:

Go over the clinical case to come to a conclusion about diagnosis and management. Discuss the difficulties in management of the case.

CASE 2

Case: 45years, male, married, uneducated, farmer

Chief complaints:

Mental illness – since 2002

Sadness of mood, not interacting with others, worrying excessively – since June 2015

Says that he and the entire family will go to jail, that they are ruined – since about Aug-Sept 2015

Reduced speech output, refusing food – Oct 2015

 

History of presenting illness: Apparently maintaining well till May 2015. From early June 2015, started worrying excessively, and over next month developed pervasive sadness of mood, decreased interest in previously pleasurable activities and day today work, would frequently complain of an almost constant sense of fatigue even after minor work.  His socialisation decreased and sleep and appetite decreased with difficulty in sleep initiation and maintenance.

In Mid July 2015, he sought treatment from a private psychiatrist and was started on some medications (details NA), with which there was development of additional symptoms. He started to remain irritable, had increased energy and activity levels, would speak excessively with pressure of speech along with most previous symptoms. Following the emergence of these new symptoms, the medications were stopped and these new symptoms resolved within few days. He was later started on Valproate 1g/d, and later other antidepressants and antipsychotics were added, and took the same with regular compliance, but perceived no improvement. From Aug-Sept 2015 started expressing mood congruent delusions of persecution, ideas of hopelessness and death wish. By Oct 2015, in addition to previous symptoms, he began to remain mute, would mostly keep lying down on bed and had staring. His oral intake reduced significantly. Following this, he was taken to a private doctor in end Oct 2015, and was given some medication, and i.m. injections. After 2-3 days, reportedly had stiffness of all limbs, sweating at times, had two episodes of fever high grade, tremors and complete mutism. He was initially treated by a local doctor, and later brought to tertiary care on 1 week prior. Here, CPK-MM levels were 815, TLC 13,000/mm3.

No h/s/o seizures, incontinence, muscle pains, myoclonic jerks, suicidal attempts, SFRS, thyroid abnormality.

Past history: Illness began in 2002, and in total had 8 episodes in the past.

Had 4 episodes (2002, 2006, 2008, 2013) of mental illness characterized by excessive cheerfulness and occasional irritability, increased energy and activity levels, increased planning, socialization, decreased need for sleep, increased self confidence, speaking faster and louder than usual, excessive spending. Each time the episode lasted for around 1 month, took treatment (details NA) and following each of these episodes had an episode similar to the index episode. These episodes lasted for 2-3 months. Since 2006, irregular treatment with Valproate 750mg-1g.

Family history: Reportedly not significant              Premorbid personality: Well adjusted

Substance use: Has been using alcohol since 20-25 years; Consumed in dependent pattern since 7-10 years, abstinent since 4 months.

Physical examination: P 88/min, febrile, BP 128/80mmHg, tremors, rigidity

Mental status examination: Oriented, psychomotor retardation, decreased amount, volume of speech, sadness of mood, anhedonia, worthlessness, helplessness, nihilistic delusions, delusion of poverty, poor insight

Instructions for students:

Go over the clinical case to come to a conclusion about diagnosis and management. What could be the DD? Discuss the management of the behavior of the patient.

 CASE 3

Case: Mrs. K, 58 female, married, B.Sc (Home Science), Home maker

Chief complaints:

• Increasing aloofness– since December 2013
• Smiling & muttering to self- Feb 2014
• Suspiciousness, agitation & aggressive behavior-since January 2015

 

History of presenting illness: Apparently maintained well till first part of November 2013. From Mid-end November 2013,became quieter than her usual self, not paying attention to or replying to queries & would appear lost in thoughts Her interactions with neighbours also decreased & she would decline invitations for social gatherings unlike previously. She also became clumsy & forgetful in routine household activities. Continued like this till January 2014 after which also started developing hallucinatory behavior. She would be seen muttering to self, responding to hallucinatory voices multiple times in day. She never provided any explanation for same. At times would become forgetful with repeated assurance seeking from husband about her safety. At other times, would stop in middle of conversation & wouldn’t be able to complete what she was talking afterwards. Since Feb/march 2015 also started expressing suspicions of husband having extramarital affair with middle aged house maid & started to keep watch on husbands day to day moves. She couldn’t be reassured to contrary & continued to act on her beliefs which led to multiple arguments & worsening of IPR between couple. Also, it was noticed that patient would make mistakes in the names of objects and people although she could recognise them and their function. Also, began to have difficulties in doing complex tasks. For these symptoms, received, T. Risperidone 2mg/day between February to March 2015 with regular compliance which was tapered off due to development of EPS and developed confusion following addition of trihexyphenidyl. T. Quetiapine 100-200mg/day was given between March 2015-October 2015 with regular compliance & 50% symptomatic improvement, yet again developed EPS. Stopped medications by herself between mid-October 2015 till presently with gradual reappearance of aforementioned symptoms. After which she was brought for assessment and treatment.

 

Past history: Nil significant

 

Family history: History suggestive of gradually progressive deterioration of memory, self-care, judgement & change in personality leading to socio-occupational dysfunction followed by death in 5 years, in patient’s grandfather, father & uncle. Age of onset was around 50 years in all of them. Grandfather & father died after prolonged illness at age 80 years & 82 years respectively. Uncle still surviving & is looked after by his family members

Premorbid personality: well adjusted

 

Physical examination: B/L fine tremors at rest, also presented on outstretched hands

Neurologic examination: Impairment in attention, naming, response inhibition, sequencing, clock drawing, Cog wheel type rigidity in both wrists. Patient walks with stooped posture, and short steps with reduced arm swings.

Mental status examination: uncooperative, grossly oriented, irrelevant speech, poor insight

 

Instructions for students:

Go over the clinical case to understand what the issues are. Whether Axis 1 and Axis 2 disorders? How would you manage the sexual dysfunctions?

 CASE 4

 Case: Mr R.K , 35 Yrs ,Married, M.Tech., asst.professor in college

History of presenting illness: Patient reports that from adolescence he has feelings of inferiority compared to his peers and others, remaining ‘tensed’, decreased self esteem, considering himself as socially inept and not appealing. He would remain excessively preoccupied with the fear of being rejected by his peers and would find it to be difficult to be assertive with them. As a result started avoiding social situations and made very few friends. This pattern has been pervasive since then resulting in difficulty in educational and occupational areas. Since 2000 onwards developed obsessive thoughts of sex and obsessive images of genitals on witnessing idols of goddesses and on visiting religious gurus, obsessive thoughts of dirt splashing on his face, sewage going into mouth, which lead to avoidance of these situations.  Around the same time developed recurrent urge to pull out hairs of eyebrows, scalp and over a period of 2 years extending to hairs of chest and pubic area, with mounting tension preceding and sense of relief following pulling of hair resulting in noticeable hair loss. While these symptoms persisted and distress increased, another set of symptoms became more pervasive and persistent which patient reports since childhood and not able to figure out exact onset, characterized by low grade pervasive sadness of mood, irritability, low energy, feelings of hopelessness, inability to derive pleasure from any activity, decreased libido, daytime drowsiness. These symptoms would mostly be present except for maximum of 6-7 days in between when patient would be euthymic. After marriage in November 2013, irritability increased, frequent altercations with wife, would not initiate sexual activity, indulged in sexual intercourse (only 7-8 times in 1 and half years) on wife’s persuasion and achieved pleasureless  orgasm. Conflicts between the couple went on increasing and became more distressing. For these symptoms, in 2005 and 2006 took treatment in the form medications (detail N/A) with irregular compliance and found not much improvement. Since 2012 has been treated with Sertraline upto 150 mg/day, Clomipramine 75mg/day, Olanzapine 10mg/day, Paroxetine 25mg/day which he took for around 2-3 years with irregular compliance found 20-30% improvement overall.

Past medical history: Not significant

Family history: Depressive disorder in mother and sister, on Sertraline and well

Sexual and marital history: decreased libido , delayed ejaculation, pain during erection & penetration. IPR problems with wife

Pre morbid personality:  anxious avoidant traits

Physical examination: fine tremors, increasing during interview

MSE:  affect – anxious, stuttering, decreased confidence, low self esteem, obsessive thoughts of sexual content and dirt, no cognitive impairment, insight : fair

 

Instructions for students:

Go over the clinical case and come to a conclusion. Is it a disorder or physiological state? What could be the effect of medications? What do guidelines say?

 CASE 5

Case: Mrs.K, 30 years, BA pass, homemaker

Chief complaints:

Mental illness since 2008

Sadness, anhedonia, suicidal ideas since October 2015

History of Presenting illness: A k/c/o episodic psychiatric illness since 2008-one episode in past (to be described in detail later ). She was maintaining well till end October 2015 during her 3rd month of pregnancy when she started having persistent sadness of mood, decreased interest in doing house hold activities, decreased interaction in family members , decrease energy, psychomotor slowing, frequent complaints of tiredness, forgetfulness, pessimistic views about future, apprehending delivery complications and ill health of child yet to come, lost hope of her recovery, thought her life not worthy of living, thoughts of ending her life by taking some poison. Sleep was delayed in onset with frequent awakening in between, appetite decreased. All these evolved over two month leading to marked dysfunction.

Past psychiatric history: two episodes in past, mania with psychotic symptoms lasting for 2-3 months ,treated with ECT, medication detail NA stopped medication two months of recovery.

Past medical – a k/c/o of DM, on t/t , was poorly controlled ,past h/o tuberculosis.

Family history: Not significant

Obstetric  history: bad obstetrics history with 2 abortions, one prolonged labour and still birth and one preterm (7th month) with death of the child after 3 day delivery, This is a precious pregnancy. Family members and patient extremely concerned about risk of medications and ECT on the child

Physical examination –WNL

MSE-restless, ideas of hopelessness, helplessness, worthlessness, ideas of guilt, wish to die, no cognitive impairment, insight-impaired

 

Instructions for students:

Go over the clinical case and come to a diagnosis. What are the problems that have developed? How to handle the same?

CASE 6

Issues:

Management of borderline personality patient with transference

Case: 23yrs, female, single, illiterate, unemployed

 Brief summary: Apparently maintaining well till Nov 2015 when she stopped taking to her boyfriend following an argument. Her boyfriend decided to break off the relationship as he was tired of repeated arguments between them. After this, she began to have repeated episodes of loss of responsiveness, wherein she would slowly fall to the floor, with her eyes closed and at times she would have tonic, non rhythmic movement of her body, lasting for 10-20mins, after which she would begin responding to concerned family members. She would have vague recollections of the  environment during the event but would report that she was unable to respond. There was no post event confusion, incontinence or injury. Initially there episodes would occur every day 1-3 times, but then after her boyfriend stopped picking up her calls or responding to her messages, these episodes have increased to 7-8 times/day. Finally, on 22nd of November, she intentionally ingested 10 tablets of her grandfathers anti diabetic medication as she wanted to end her life and also wanted to ‘teach her boyfriend a lesson’. She reported the ingestion immediately to family members who induced vomiting. Following this, she was brought to your centre and admitted.

Past history: h/o previous attempted self harm on 2 occasions following interpersonal stressors with friends and family members

Family history: Brother - opioid (heroin) dependence

Premorbid personality: impulsive, frequent mood swings, forms intense friendships but unable to maintain the same

Physical examination: scars of slash marks on left forearm

Mental status examination: smiling at therapist, asking personal questions, got angry when the therapist didn't encourage the same. When details of her previous relationship were inquired into, had an unresponsive spell. However, plantar reflexes were flexor, pupils were reactive at the time. No post event confusion, conjunctival injection or incontinence.

Course in the ward: After initial few counselling sessions, her previous symptoms resolved completely within the week. She then began to tell her family members that you are the best doctor in the world. Also, she began to gift you prasad, make small cards that named you best doctor. She began to demand that you come and see her atleast 4 times a day and speak with her for atleast  20-30mins at a time. When explained that this would not be possible, she began to angrily say that you had no interest in her well being and you were a very bad doctor. Then once again began having episodes of unresponsiveness. When her discharge was being discussed, she started crying as ‘no one cared for her’ and been to threaten that she would kill herself if discharged against her will.

 

Instructions for students:

Go over the clinical case and come to a diagnosis. What is the most likely diagnosis and why? What would be the management?

 CASE 7

Issues

1. Differential diagnosis

Case: Mr S K, 22Y , Single , BA second year pass, currently unemployed

History of present illness: apparently maintaining well till late 2008(while In class 8th) when started smoking chillums of cannabis and drink beer with his friends. Initially, he would smoke only occasionally for the next 2-3 years but since 2012, he began to smoke regularly, 3-5 chillums each day and began drinking alcohol every day, 180-250mL of whisky, in a pattern characterised by craving, withdrawal, tolerance and inability to control his intake. Following this he began to have 3rd person auditory hallucination discussing patient with derogatory content. He also began to voice that people around him were discussing about him and wanted to harm him. He additionally at times would feel that his thought and actions were not his own but were being controlled by his neighbours. He would get angry on minor matters and would constantly appear irritable. He would also smile to himself and laugh inappropriately at times. He would also get aggressive and violent towards neighbours without clear provocation.  He would not take self care and would be in a disheveled state. Following 3 months of these symptoms, family members took him to a private psychiatrist, who treated him with T. Olanzapine 10mg/day and patient was admitted in a deaddiction centre for 6 months. He was completely improved when he returned home after 6 months, was declared cured and all medications were stopped. He began to work as a carpenter and remained well for the next 2 years when once again in June 2015, he began to smoke cannabis. Again intake increased to 2-3 chillums each day. Following  this, after 2-3 months, he once began to have symptoms as previously. He was then brought for assessment and treatment.

Past history: Conduct traits in childhood

Family history: Not significant

Physical examination: Cachexia, pallor

MSE: restricted range and reactivity of affect, delusion of persecution, thought insertion, third person auditory hallucination of derogatory content, thought echo, no cognitive impairment, insight: poor

 

Instructions for students:

Go over the clinical case and come to a diagnosis. What are the striking issues? How would you evaluate the child? What would be your management?

Case 8

Case: Master M, 11Y , Single, student of class 6

History of present illness: The child was born premature at 8 months of gestation and developed neonatal jaundice for which he required ICU stay for a few days. Father is unaware of early developmental milestones as the child was with the mother during the first 3 years of his life. However he reports that the child currently has difficulty in calculating money, understanding complex instructions, plays with children younger than his age and performs poorly academically. He says that even her younger daughter (8 years of age) is ‘smarter’ than him. Also, as per the father, since the time he can remember the child has always been fidgety, unable to sit still for more than a couple of minutes, not wait his turn, frequently interrupt others, get angry if he was not immediately gratified. Teachers would complain that he would be inattentive in class, forget instructions and had to be repeatedly explained before he could understand even simple concepts. Around 6 months ago, his parents have divorced and he is currently staying with his father and paternal family. Now since the last 3-4months, the child has started lying, at times steals money from his father’s wallet and spends it on buying chocolates. He has begun to bully his younger sister and cousin, frequently back answers his father and grandparents. He also has become more aggressive and demanding, and has on few occasions broken household items when demands are not met.  He recently had a physical fight with his classmate following which he was referred for evaluation.

Family history:  h/o alcohol abuse in the father but severe interpersonal problems in parents with mother not getting along in  in- laws house

Psychosocial history: Child’s parents have been having frequent interpersonal problems since the time of their marriage. Mother had delivered the child at her parental place and stayed there till he was around 4 years of age. Following this, she returned to her marital home, but interpersonal disputes continued. The couple divorced 6 months ago, with the mother leaving with her younger daughter and the patient staying with the father. Father frequently criticizes the child, compares his behavior and academic performances with other children. He believes that the child is lazy and disobedient, frequently beats the child when he makes mistakes.

Physical examination: Ht-120cm, pallor

MSE: Child is constantly fidgeting while sitting on the chair and frequently interrupts when the therapist was interviewing his father. He also pushed another child who was playing with a toy he wanted. He could not do simple calculations, nor could he name more than 5 animals, nor identify similarities. Writing resulted in broken sentences with simplistic concepts.