Pramod Shendade

I am presenting the case of a 27-year-old Hindu unmarried male residing in Surat, belonging to lower
socioeconomic class, speaking Hindi and Marathi, was brought to OPD-13 by his mother and admitted
to J0 ward under Psychiatry department, NCH Surat. Interview was taken in private as well as in front
of relatives. History given by the relatives was reliable and adequate. The patient presented with chief
complaints of-

According to the patient, “Muje kuch nhi hua hai, meri tabiyat toh achi hai.”

According to his mother:

● Ran away from home
● Aggressive and violent behaviour
● High talks
● Claiming to have super powers
● Talking excessively without provocation
● Overfamiliarity in the form of going up to random strangers
● Decreased need for sleep

According to his mother, the total duration of his illness is 7-8 years, which is an episodic illness and
have had total of 4 episodes.

History of present episode:

Patient was apparently asymptomatic 3 months ago; he was on regular medication from Dhulia which
was Tablet tfp 15 mg, Tablet Amisulpride 200 mg, Tablet Bupron 150 mg and was working at his job
when his mother started noticing changes in his sleeping pattern as he started getting up earlier and was
would also go to sleep late at night. She assumed that it might be due to the stress at work, but he also
started staying irritable as he would get angry and shouted at his family member on petty reasons. His
mother then suspected that he might be skipping his medication as he would usually complain about
the drowsiness caused by his medication. On inquiring about the same, she found out that he was
skipping dosages of his medication. She tried explaining to him about taking medication regularly, but
he would start shouting and would threaten them that he will hit them or harm himself. So they did not
force him, meanwhile he also started interacting with strangers on the road whenever he would go to
his job or in his neighborhood. So, the family took him to the psychiatrist in Dhulia, and his medication
was changed. He was compliant on medication for around 15 days then again, he started to skip the
dosages as he felt he did not need medications. Then after this, he started staying very happy and also
started claiming that he has an account is SBI bank and he has a lot of money in that account. He would
claim that he had many contacts abroad and in India which will help him to get anything he wants. On
2 separate occasions, he left home without informing anyone and went to a temple 50 kms away and
returned after 1 day. On asking about this he said that he just went there to pray to god. This went on
for a few days and during Navratri, he ran away from his house. After this the family filed a missing
complaint in police. He was found 2.5 months later by police in Indore, Madhya Pradesh and the same
was conveyed to the family. He was found roadside and was in a very bad state when found. He hadn’t
bathed since many days as evidenced by his dirty clothes. He also had a beard and long hair. He was
then taken directly to Dhulia for admission under a psychiatrist. He was admitted for 3 days and was
started on IV fluids and mood stabilizers. According to the family, he was very aggressive at that period
of time and was given multiple injectables during the hospital stay. He would also not sleep at night
and would keep talking how he will join Indian army and how he has knowledge of martial arts like
Jackie chan. He was started on multiple medications in these 3 days, and the patient was discharged on
oral medication. After 8-9 days at home, he had an episode of tonic clonic movement of limbs with
frothing from mouth. He was unresponsive for 4-5 minutes. He had another episode when he was being
taken to the hospital. He was again admitted to a different psychiatrist this time for around 15 days
during which according to the family he had no improvement in his symptoms although he did not have
any other episode of seizure. After this due to financial constraint, the family was advised to take the
patient to new civil hospital, Surat. When patient presented to OPD 13 he was on -
T Clozapine
T quetiapine
T Tfp
T Chlorpromazine
T Aripiprazle
T lithium
T lamotrigine

Patient was admitted as he was very disruptive and had history of running away from home.
During the ward stay patient was started on injection haloperidol phenargan 12 hourly
And some changes in medication weree done. He is currently having fever since 2 days. Sleep and
appetite are assured at present.

Past History:
The patient was relatively asymptomatic 8 years ago and had just passed his 12th standard. He wanted
to give exam and wanted to work in railways, he was also preparing for the exam. His mother noticed
a changed behaviour in the form of studying all night without sleeping, and would sleep only for 3-4
hours after studying. He would also report that he feels fresh after 3-4 hours of sleep and does not
require sleep any further. After this he started staying irritable as he would start shouting at home even
on trivial matters like why the dinner is cold, why is his clothes not ironed. His family thought it was
the stress of securing a job and railways exam. He also started praying early in the morning and also
going to the temple everyday. He would spend 2-3 hours in the temple every morning. Then he started
not sleeping at all and roaming around the city at night. Patient also started physically attacking family
members if he was denied anything. Then the family took him to a private psychiatrist in dhulia where
he was admitted for 15 days. Documentation is not available but patient was given ECT’s and multiple
injections according to the family. He gradually got better and got 100% better during the admission.
Patient then continued medications for 6 months, but during this the patient had an episode of jerky
movements of limbs associated with frothing of mouth. It was also associated with uprolling of eyeballs.
He was taken to the doctor and medication was changed.
After around 1.5 years, his colleagues at work advised him to stop medication as he was normal. He
stopped medication and was asymptomatic for 1-2 weeks but started having behavioral disturbances
which then developed into similar symptoms as last episode. Again he had to be admitted as he was
disruptive at home. He was admitted for 10-12 days, but gradually got 100% better in 3-4 months on
medication. But he continued his medication regularly since then and was fully functional for the next
4 years.
The next episode happened after his father met with an accident and he stopped medication under stress.
He had similar symptoms as previous episode and got better after restarting his medication.
He was not admitted for this episode and the he got 100% better within 2-3 months. After that the
patient was on regular medication since this episode.
SUBSTANCE HISTORY-
1. Cannabis – History of intake of cannabis present, exact details of intake were not known to the
parents. But according to mother, pt took cannabis in the form of ganja once or twice with his
friends and stopped after his father came to know about the incident. He also had intake of
bhang goli at the occasion of Holi. Both the intake were around 8 years ago and the family
claims that he has not taken cannabis since then.

NEGATIVE HISTORY:
No h/o hearing of voices, disorganized speech, self-muttering, any abnormal postures.
No history suggestive of repeated thoughts of contamination, of repetitive hand washing, checking,
counting, etc.
No history of HIV/Encephalitis/Substance use disorder.
No history of features of autism or pervasive developmental disorder.
No history of any stereotyped movements or problem in communication with others in childhood or
even during this episode.
No history of hematemesis, ascites, head injury or per rectal bleeding.
No history of DM, HTN, any other medical or surgical co morbidity.
No history of any other substance abuse.

FAMILY HISTORY:
Patient is the 2nd child among 4 siblings. Both the sisters are married and stay with their in laws.
His younger brother is studying in Patna and is currently looking for a job.
Patient is unmarried as his mother claims the illness being the primary reason.
Mother works as a cleaner in her neighborhood and father is a driver.
There is no history of psychiatric illness in the family, but father has a history of cannabis use.

1. Perinatal history:
NAD

2. Childhood history:
Reached all developmental milestones on time.

3. Educational history and Occupational History: Studied up to 12th standard and was a good
student. He was regular in school and got average grades. Reason for not studying further was
due to start of his illness. After his 1st episode of illness subsided, he started working at a private
company as a laborer. He would stop working when he had episodes of illness and would restart
working after recovery from the illness. Currently, he is unemployed since 3 months as he
stopped medication and ran away from home.
Personal history:
Bowel/ bladder-normal
Appetite- decreased at present.
Sleep: sleep assured inside the ward.
Premorbid personality-
Patient was pre-morbidly well-functioning. He was socially interactive but had an introverted
personality as evidenced by his few friends. He was good in studies and did not have any complaints
from school. According to his mother he was very supportive and would help other siblings and parents
at home. He had good relations with his extended family and his friends at school.
Physical Examination:
General Examination:
I have examined my patient in proper light and exposure. His BP 110/70 mm hg in supine
position. His pulse rate 110/ min in right radial artery with normal rate and volume. No signs
of cyanosis, clubbing, pallor.
A scar mark is seen on the right forearm of the patient, which was a tattoo of B.R Ambedkar
and was made by him during an episode of the illness.
Currently the patient was having fever spikes for which relevant investigations have sent and
physician opinion was taken.
Systemic examination:
CVS S1, S2 Normal, no murmur
Respiratory: B/L air entry normal, no added sounds
Per abdomen- Soft, no organomegaly
On examination of CNS
Higher Centre- Patient Conscious oriented to time, place and person.
All cranial nerves intact
Motor System- Power Grade V in all 4 limbs
Nutrition, coordination: normal
Sensory System - normal
Mental status examination:
Appearance and behaviour-

A 27-year-old male patient with average built and nourishment and average grooming and
hygiene wearing a t-shirt with a picture of Shivaji Maharaj and black jeans. Patient seems to be
of the stated age. He walked into the examination room with his mother after being asked for 2-
3 times and was reluctant to sit down at one place. Throughout the interview he would keep
getting up and wanted to go outside. Rapport was established with difficulty and was difficult to
maintain throughout the interview.

Eye to eye contact:

Initiated and not maintained throughout the interview, as patient would have to be called twice
or thrice to look towards the examiner.

PMA:

Increased as patient keeps getting up throughout the interview and had to be asked to sit down
again and again. There were gestures of singing and smoking whenever relevant questions were
asked. He also performed karate moves during the interview.

Speech:

Spontaneous with increase tone and volume, with increased productivity and decrease reaction
time. Slurring is present in speech in the ward stay which was absent at the time of admission.
The speech would sometimes be incomprehensible as the patient would speak so fast.

Mood: On asking apka mann kesa hai ?

He replied “ Acha hai par muje yaha nhi rehna hai, yaha kuch karne ko nahi hai. Muje Naukri
pe jana hai apni.”
Affect: Inferred as Irritable, not congruent to mood and inappropriate to surroundings with
decreased range and increased reactivity. No labile affect seen.

Thought: Form and stream of thought- On asking to speak about a neutral topic – What he
wants to do in life?

Patient said “Ab me kya hi batau apko muje Indian army me jaana hai. Me Jackie chan aur
bruce lee se seekhke aya hu . Boht power hai mujhme aur me abhi army me jaake commander
banunga. Ye dekho meri tshirt pe bhi Shivaji ki photo hai, ye hamare Bhagwan hain aur inki
pooja karte hai hum. Then the patient started singing religious songs.”

Inferenced as flight of ideas.

Content – On asking patient “aap saara din ward me kya krte ho aur kya vichar karte ho”?

Patient first started smiling and then said “ Meri

Perception: Patient was asked “kya aapko koi khaas Anubhav hote hain? Jese ki akele bethe
huye jab koi aspas na ho toh awaz aati ho?”

No perceptual disturbance found at present.

ATTENTION and CONCENTRATION:

Patient was not able to do serial subtractions from 100-7, not able to count backwards from 20
to 1 even after 2-3 attempts. He registered the questions appropriately but got distracted before
giving answers.

Inferred as poor attention and concentration.

Memory:

Immediate: Patient was able to recall the names of all three objects presented to him
immediately.

Recent: Able to tell the breakfast content.

Recent past: Able to tell the name of latest festival.

Remote: Able to tell the names of childhood friends.

Inferred as intact memory

INTELLIGENCE AND FUND OF KNOWLEDGE:

Was able to tell the name of the Prime Minister. Patient was able to tell the 5 cities in India, He
started talking about his hometown in between the question.

Inferred as average fund of knowledge as per age, qualification, cultural and social background.

ABSTRACT THINKING

Upon asking the patient, Paancho ungli ek barabar nhi hoti

Patient replied dekho ye hai meri 5 unglian sab alag alag hain.

When asked to explain what he means by this “he started speaking in marathi and even his
mother could not tell the meaning of his verbatim.”

On asking about apple and oranges “ He said he doesn’t know about any of them.”

On asking another proverb he got irritated and didn’t answer next question.

Inferred as Impaired Abstract.

JUDGEMENT:

Social Judgment: Appears to be impaired as the patient is distracted during interview, Kept
laughing during the interview and even touched the examiner during the interview.

Test judgement: Upon being asked, “Yaha pe aag lgegi toh kya kroge?

Me army ko bulaunga aur aag ko bujha dunga. And then he started talking how he went to
Nepal for free as he have so many contacts in all countries.

Inferred as impaired test judgement.

INSIGHT:

Upon asking the patient, “On asking the patient why is he admitted in New civil hospital ?

He replied , “ Mujhe mera bhai aur mummy pakad ke laye hain aur muje kuch hgya tha
dimaag me. Par pata nhi kya hgya tha. Abhi me theek hu.

Inferred as Grade 2 insight.

Diagnosis:

DSM 5: bipolar 1 disorder with current or most recent episode Mania.

ICD-10: Bipolar Affective Disorder, current episode Manic with psychotic symptoms- F31.1