COUNSELLING PSYCHOLOGY & GUIDANCE

CASE REPORTS

CASE HISTORY 1:
Name : NA

Age : Above 18 (specified only as adult)

Gender : Male

Education : NA

Occupation : NA

Marital status : Single

Financial status : Low

Chief complaints :
 Hearing voices for the past 10 months
 Loss of appetite
 Physically abusive to his mother and sister.
 Felt unsafe & people wanted to harm him

Duration :

 10 months
 Course of illness – unsafe, heard voices

History of present illness:

An adult male who was seen at a psychiatric unit complained of hearing voices for the past 10
months and loss of appetite. He also complained that he roamed around town, and even though he
returned home, he was sometimes physically abusive to his mother and sister. The patient further
added that he felt unsafe and thought that people wanted to harm him.
The patient explained that he took a leave from work because he was feeling feverish and asked
someone to replace him, but he never returned to the workplace. A month after commencing
leave, he received his salary for work done but subsequently was not paid by his company. He
decided to move from one bank branch to another, trying to make withdrawals. On his third
attempt at one branch, he was arrested and put in cells for four days, but he was never given any
reason. He said he had also received death threats, one of which was a call from an unfamiliar
number. No words were spoken, but he perceived that it was a signal that meant that his life was
to be taken, his sister also reported this.
His social history revealed that he lived in the city with his mother and sister. He had a girlfriend
who stayed at a different suburb of the city.
When the patient was first seen at the psychiatric unit, relevant signs included complaints of
difficulty in sleeping, loss of appetite, roaming around town.
The patient experienced auditory hallucinations. He complained of hearing voices and engaged in
third person conversations involving both a man and a woman. The patient also complained that
he heard people talking about him and insulting him, some of whom he knew. He was therefore
suspicious and felt uneasy with others. He believed that he had been targeted. His thought content
revealed paranoid delusions and delusions of reference.
His risk factors included being born and raised in an urban area and male sex which put him at
risk of paranoid schizophrenia.

Negative history:
No H/o suicidal thoughts

Past psychiatric history:

Paranoid delusions

Biological history:
Not available

Family history:
Not available

Family history of mental illness:

Not available

Personal history:
Behavior from childhood- Introvert

Use and abuse of alcohol

Not engaged in any illicit drug use prior to the onset of his current symptoms.

Pre-morbid personality:
▪ Interpersonal relations – BAD
 ▪ Hobbies and interest – NA

▪ Subjective Mood – Repeated several times that there was nothing wrong with him.

▪ Objective mood – Absent

▪ Attitude & work responsibility – POOR

▪ Habits

o Eating pattern – NA

o Sleeping pattern- POOR

Mini- Mental Status Examination:

 Emaciated & appeared
 Informally dressed
 Apprehensive behavior, fatuous laughter, and hesitancy
 mood was depressed and affect constricted
 Thought form : Not normal
 Thought content: Unsafe & Repeated several times that there was nothing wrong
with him
 Perception : Auditory Hallucination
 Attention and concentration : Impaired
 Insight: Poor

TREATMENT:
 The patient was prescribed with IM haloperidol 10 mg and IV diazepam 10 mg,
for rapid tranquilization when he was admitted due to aggression, this didn’t yield
any favorable results.
 Changed to IM midazolam 7.5 mg and IM haloperidol 5 mg
 Trihexyphenidyl 5 mg tablet was prescribed upon the recommendation of the
clinical pharmacists. The dose of olanzapine was also reduced to 5 mg upon
recommendation by the clinical pharmacists.
 The patient underwent four cycles of electroconvulsive therapy with IV Ketamine
500 mg and IV haloperidol 10 mg. These were done on the 2 nd, 13th, 16th, and
18th days of hospital admission. The patient’s mood, appearance, behaviour,
 perception, and insight improved while on therapy. Although he was occasionally
restless, he was mostly cooperative.
 He was scheduled to be discharged on IM flupentixol 40 mg every 4 weeks and
olanzapine 5 mg tablet daily. The clinical pharmacists intervened for the dose of
IM flupentixol to be reduced to 20 mg. Therefore, the patient was discharged after
25 days of hospital admission on IM flupentixol 20 mg every 4 weeks and
olanzapine 5 mg tablet daily (to be tapered off in 3 months). The patient however
failed to report to the hospital for a psychiatric follow-up.

CASE HISTORY 2:
Name : NA

Age : 73 years

Gender : Female

Education : Completed High School

Occupation : Clerk

Marital status : Married (widow)

Financial status : Middle Class

Chief complaints :
 Worsening memory impairment
 Difficulty finding words

Duration :

o Total duration - 3 years

o Age of onset- 70 years
o Course of illness- Worsening memory impairment

History of present illness:

A 73 year old woman was brought to neurological evaluation by her brother because of
a 3 year history of memory impairment. She had completed high school and worked in a
clerical position until her retirement in 1985. She had lived alone and maintained her
own home and financial affairs since the death of her husband in 1980. The brother had
 begun to notice gradually worsening memory impairment and difficulty finding words,
but the patient became angry at the suggestion that she may have a progressive
impairment. Others had noted decline in housekeeping and financial affairs, but she had
no complaints.
Elevated arterial blood pressure was documented on several occasions, but she never
took medication. She had no children and had a hysterectomy. General and elemental
neurological exams were normal.

Negative history:
No H/o suicidal thoughts

Past psychiatric history:

NO H/o past psychiatric problems

Biological history:
Not available

Family history:
Not available

Family history of mental illness:

Not available

Pre-morbid personality:
▪ Interpersonal relations – GOOD

▪ Hobbies and interest – NA

▪ Subjective Mood – Had no complaints about herself

▪ Objective mood – Absent

▪ Attitude & work responsibility – POOR

Mini- Mental Status Examination:

 Well-groomed woman
 Alert and friendly
 Speech - anomic and paraphasic,
  Memory : Able to recall dates.
 Orientation-
Unaware of the year of her birth, the current year, or the name of the current U.S.
President.

DIAGNOSIS:
 On formal testing, she scored well below average in all cognitive
domains. These tests included the Wechsler Memory scale, the
Wechsler Adult Intelligence Scale, digit span and similarities
subtests, the Boston Naming Test, the CERAD Word List Memory
Test, the CERAD Visuo-spatial Construction, the Cross Circle
Tests, the California Proverb Test, and the Graphomotor
Alternation Test. She tended to perseverate both verbal and motor
responses

 The conclusion of the evaluation was that she met research criteria
for "probable" Alzheimer's disease, that she required complete
supervision around the clock to insure her safety, and that she
would probably benefit from social stimulation provided by a
group living situation.

SUSHMITHA A | E20PC035