NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA

(FULL REPORT)

# Candidate’s information
1 Surname: ADELAJA Other names: ADENIKE SILIFAT
2 Training institution: ABUTH ZARIA
3 Rotation institution (if different from the training institution): Click here to enter text.
4 Supervising consultant for the rotation: DR AUDU I.A.
Period of rotation: 6 MONTHS
5 From m/d/y: 9 To m/d/y:
6 Posting: GENERAL PSYCHIATRY

Patient information
7 Initial: P.M

8 Date admitted 9 Date discharged m/d/y: 9

m/d/y:

Details: 2000-2500 words (Remember to anonymized the Sociodemographic and other relevant
data)
9 25-year-old male, single, student brought by father.
PC – Undue excitement
Undue generosity
Decrease need for sleep, all of 1 week duration
HPC – she was in her usual state of health until 5 months following her delivery when
she became unduly excited for no apparent reason. She described herself as being
extremely happy.
Also, she was noticed to be sharing her things to people, clothes, including her to baby
materials, almost sold her television also to give to people. This she said was because
people need them however, she was told it were abnormal.
Moreover, patient found herself to be sleeping less unlike before but engaged in
numerous activities while awake in the night, washing dishes, cooking, washing
clothes etc.
She also thought herself to be a special person, however could not specify, this made
her to talk to people anyhow without fear
These was no history of increased libido or sexual indiscretion, no history of undue
sadness, no hearing voices of unseen persons, nor seeing images unseen by others. No
verbal or physical aggression, no history of febrile illness, tremors of the hands,
trauma to the head or anterior neck swelling.
Since the onset of the illness, patient was unable to care for her baby as expected by
the family members.
This made them to bring her here.
Past Psyche: Index is 2nd episode. 1st episode is last year April, similar pattern of
symptoms, preceding by 4 years of Cannabis use.
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 NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA
(FULL REPORT)

Had outpatient treatment and subsequent drug (Cannabis) treatment for 4 months.
Discharged on medications, but defaulted follow up and medications.
No known history of undue sadness low energy in the past.
Family Hx: 3rd of 3 siblings parents are police. 1st sibling – married, works with road
safety, lives in Jos.
2nd sibling – female, single, police woman, lives in Abuja.
Patient is closest to the mother. No known family history of similar illness.
Personal history;
Perinatal – {not aware
Milestones –
Places of upbringing - Before parents & aunt.
No history of childhood disorders
-
- No history of abuse

Primary school – Karu primary school 2010

Secondary school – 2014 SS2 WAEC
Highest education is diploma (Nuhu Bamalli) 2016/17
Occupation – unemployed
Sexual maturity – can’t remember
Relationship – has a friend, 1 year now. Has a baby with previous relationship – 1 st
sexual contact with the 1st friend, consensual
Drug history- nil of note
Forensic history – nil of note
Currently living with parents’ circumstance
Social and financial support is parents
Premorbid personality - free few friends
- Talking type
- Optimistic
- Not religious
- Cheer
- Music listening
Appearance & Behavior - a young woman appropriately dressed co-operative, no
motor abnormalities
Speech - spontaneous, coherent, relevant, normal volume & tone
Mood - euthymic
Affect - appropriate
Thought - stream – normal
- form – normal

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 NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA
(FULL REPORT)

- content- normal
- possession - normal
Perception - nil
Cognition - conscious and oriented
- attention and concentration, secured & sustained
- memory I-Good
R-Impaired
R-Good
- intelligence arithmetic- good
Fond of knowledge good
Abstraction – good
- judgment poor
Insight partial

Physical examination
Afebrile, not Pale
CNS: Conscious, no focal neurological deficit
CVS: PR – 70b BP-110/70 mmHg
Summary: – 25-year-old female single, unemployed, admitted 2 months ago with
a week history of – undue excitement, generosity and reduced need for
sleep. No psychotic symptoms and no abnormality in physical examination.
Items of phenomenology –
1. Elevated mood
2. Increased energy
3. Reduce need for sleep
4. Financial indiscretion
5. Neglect of baby care
Multi axial diagnosis
Axis 1 - Bipolar affective disorder (mania without psychotic
Symptoms)
Axis 2 - personal function – 2
- family function – 2
- occupational function – 3
- societal function – 3
Axis - predisposing
Bio –
Psychological –
Social –
Precipitating

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 NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA
(FULL REPORT)

Bio –
Psychological –
Social –
Perpetuating
Bio –
Psychological –
Social –
Treatment
Multidisciplinary stepwise wholistic and yet individualized, using the biopsychosocial
model.
In the short term: would life to achieve remission of symptoms and insight.
Long term: relapse prevention and rehabilitate back to the society.
Investigation: Bio- FBC, Urinalysis, LFT, RBS
Psychosocial- Family dynamics along with social worker
Treatment: Bio- antipsychotic Olanzapine
Psychosocial- Psychoeducation

Prognosis
Good----Female, good premorbid adjustment, short duration of untreated illness,
negative family history and absent high expressed emotion
Poor: Single, single parent and poor insight

10 Attestation: ☒I attest that this report is a correct representation of my clinical

encounters with the patient in reference.
11 ☒I attest that my supervising consultant previewed this write-up
before upload.

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