CASE PRESENTATION

DR.RIYA
PERSONAL INFORMATION

• Name: Mr. R
• Age: 23 years
• Gender: male
• Educational qualification: 12th std.
• Occupation: -
• Religion: Hindu
• Marital status: unmarried
• • Resident of Manesar , Gurgaon
• Socioeconomic status: Lower socio-economic status
INFORMANTS

•Informants
• SELF
• Father : 46-year-old male, juice vendor. Stays with the patient
in the same house.

The information provided is clear, coherent and in chronological

order. The information provided is reliable, adequate and complete.
CHIEF COMPLAINTS

Self : “ghar wale mujhe tang karte hai”

“mujhe maarna chahta hai ”

According to mother : “ulti sidhi baatein karta hai ”

“ shak -vehem karta hai”
“ gussa karta hai”
“nahata nahi hai , khana bhi kam kha rha hai” x
10 days
COURSE SPECIFIERS

• Onset: acute
• Course: Continuous
• Duration: 10days
• Precipitating factors: - Nil
• Perpetuating factors: - Nil
HISTORY OF PRESENT ILLNESS
• Patient was apparently well 10 days back when his father started
noticing some changes in his behavior. He first noticed that his
interaction with family members has decreased than before and that he
was keeping more to himself. He would not talk to them and would
get irritable when they would try to talk to him.
• Over the next few days , his irritability increased, and he started
saying to his father – “तुम मुझे गड्ढे में डाल रहे हो ; तुम मेरे साथ गलत करते हो” . On
being asked by his father as to why he was saying so , he would not
reply and would get up and walk away.
HISTORY OF PRESENT ILLNESS
• His suspiciousness towards his family members increased over the
next few days and he also started to refuse to eat food at home saying
– “isme zeher mila kr de rhe ho tum mujhe ; mujhe maarna chahte ho
tum log”.
• Along with this , his family members also noticed that he would go
out of the house without informing anyone and would not return for
the next 8-9 hours. His parents would repeatedly try to call him, but he
would not pick up the call. When he would finally come back home ,
his family members would inquire about where he was and who he
was with , to which he would not reply to them and would straight
away go to his room. He would not even come out to have his food.
HISTORY OF PRESENT ILLNESS
• Family members also reported that the patient was sleeping less.
Earlier he would sleep for 7-8 hours but now he was only sleeping for
2-3 hours.
• He also started getting aggressive towards his family members. He
would mostly stay in his room and refuse to come out and if his family
members would try to get him out of his room even for having his
meals, he would get very angry and in one such instance he also
started breaking things around the house. When his father tried to calm
him down , he got verbally abusive towards him and started saying the
same things – “tum sab mere against ho ; mujhe maarna chahte ho ;
mujhe gaadhe me daal rhe ho”
HISTORY OF PRESENT ILLNESS
• He also stopped taking care of himself. He stopped taking baths and
had to be repeatedly asked by him family family to take bath. Despite
this he would not take baths.
• Over the next two days his father noticed that he wasn’t sleeping at all,
was continuously pacing in his room and and did not even eat. Seeing
all this his father got very worried and he was then brought to SGT
hospital the next day for further evaluation.
NEGATIVE HISTORY

• No h/s/o seeing or hearing things not perceived by others.

• No h/s/o head injury, loss of consciousness, jerky body movements.
• No h/s/o persistent and pervasive change of mood, suicidal ideations
or attempts
• No h/s/o over cheerfulness, decreased need for sleep, big talks.
• No h/s/o consumption of any other substance.
PAST HISTORY

• Patient was apparently well 3 months back (June) when he started

complaining of “ghabrahat” to his family members. He reported
experiencing ghabrahat along with shortness of breath and palpitations
and he would be seen continuously pacing around to calm himself
down. These episodes would last for 10-15 mins after which he would
slowly calm down.
• Over the next few days , he started to experience these episodes more
frequently (2-3 times per day while initially they would occur 1-2
times in a week ) and found it difficult to calm himself down.
PAST HISTORY
• He started saying to his parents that he was worried about his future ,
about how he would do things, whether he would be able to find a job,
if things will work out for him or not. He would be very preoccupied
with these thoughts, and this would cause him more distress.
• One day he started complaining of experiencing chest pain along with
ghabrahat and difficulty breathing and he was brought to SGT
Hospital for further evaluation.
TREATMENT HISTORY

• Patient was given :

1. Tablet Escitalopram 5 mg BY MEDICINE DEPARTMENT
2. Tablet Clonazepam 0.5 mg

• Patient and parents reported that , patient started experiencing relief

within 3-4 days of taking the medications. Patient took these
medications for 3 months was was maintaining well on these. Post this
the patient stopped his medications on his own as he reported that he
was completely okay.
FAMILY HISTORY

• Patients belongs to a nuclear family. There are 4 members in the family.

• Patient has 1 younger brother.
• Father is the head and decision maker of the family and the sole bread earner.
• No h/o substance use in the family or history of suicide in the family.
• Patient’s family perceive patient's symptoms as a mental illness and want him to
seek treatment from a hospital
FAMILY GENOGRAM

46yrs 35yrs
(juice vendor) (housewife)

23yrs 21yrs
PERSONAL HISTORY

• Birth and developmental : Full term normal vaginal delivery at hospital. Cried
immediately after birth. No history suggestive of developmental delay.
• Behaviour during childhood : Was a shy and timid child. No h/o temper tantrums.
Would play with his brother.
• Physical illness during childhood : No h/o any major/prolonged illness during
childhood
• Schooling : Started schooling at the age of 5 years. Studied in an English medium
school till class 5th in U.P, then shifted to Hindi medium school in Gurgaon and
completed his schooling till 12th. Academically average in studies, did not have many
friends. Joined a computer course online after 12th but left the course 3 months back.
PERSONAL HISTORY

• Sexual history : Heterosexual in orientation. Attained puberty at 14 years of age.

• Occupation : -
• Marital history : Unmarried
• Substance use : No h/o any substance use
PREMORBID PERSONALITY

• Social relations : Patient had a cordial relationship with his family members and
friends.
• Intellectual activities, hobbies and use of leisure time : patient would spend his
spare time by watching tv or videos on YouTube or going out to meet his friends.
• Predominant mood : cheerful
• Character:
• Interpersonal relations : patient had a cordial relations with family. Patient was
not very social and had few friends.
PREMORBID PERSONALITY

• Attitude towards work and responsibilities: Helped with chores and

responsibilities around the house.
•Religious belief : religious but occasionally performed rituals.
• Habits : denies any use of substance. Used to sleep for 7-8 hours/day.
GENERAL PHYSICAL EXAMINATION

Patient is conscious, cooperative, well built.

• Weight— 58 kgs Height— 177cms BMI – 18.5
• A prolapsed mass protruding from the anal region , associated with pain and blood
while passing stools ( Surgery opinion done for the same – Haemorrhoids)
• Vitals:
Pulse Rate- 84 bpm
Blood Pressure- 126/80 mmHg
Respiratory Rate- 16 per min, regular in rhythm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal oedema
SYSTEMIC EXAMINATION

• Cardio-vascular system:
S1, S2 heard, no murmurs heard.
• Respiratory system:
B/l symmetrical; respiratory rate- 16 per minute B/l equal movement of chest.
• Per abdomen examination:
no local rise of temperature or tenderness, no organomegaly.
SYSTEMIC EXAMINATION

• Central nervous system:

 Patient is conscious, oriented.
 Normal gait and posture
 Cranial nerve examination normal
 Muscle tone : normal
 Muscle power 5/5
 Superficial reflexes : Abdomen ++ , Planter : flexor
 Deep tendon reflexes :normal
 No sensory deficit elicited
 No signs of cerebellar dysfunction
MENTAL STATUS EXAMINATION

• General Appearance and behaviour : A thin built man walked into the interview
room sat on the chair, did not greet the examiner. He was ill kempt, not dressed
appropriately according to the situation (without his shirt) Overall personal
hygiene was inadequate.
• Eye to eye contact: not established.

• Rapport: established with difficulty

• PMA: increased
MENTAL STATUS EXAMINATION

• Speech :
Pitch/Tone : increased

Volume: normal

Reaction time : normal

Clear and coherent

Mood and Affect – (S) “ mai bilkul theek hu” (O) irritable

Range : restricted Reactivity : present

Lability : absent
MENTAL STATUS EXAMINATION

• Thought : Form – no formal thought disorder

stream – normal
Content :
“LT matlab sham hoti hai ; RT matlab subah hoti hai; koi doctor nhi hai yaha pe ;
aapko nahi samjh aayega .”
“Ghar walon ne dawaiyon ke paper pe stamp lgwa liya hai; galat dawai dete hai
mujhe; mujhe maarna chahte hai; gaadhe me daal rhe hai mujhe ”

Inference : Delusion of Persecution

MENTAL STATUS EXAMINATION

• Perception : No Abnormality elicited.

HIGHER MENTAL FUNCTIONS

• Orientation : Patient oriented to T/P/P

• Attention and concentration :

Serial substraction test: able to do 100-7 upto 4 times in 40 seconds.

Immediate : Digit forward – upto 4 digits
digit backwards upto 3 digits

•Impression : Attention arousable and sustained.

HIGHER MENTAL FUNCTIONS

• Memory : Could not be elicited ( Patient was not able to sit for the same and was
complaining of pain in the anal region )
•Immediate : 3 object test
•Recent : what did the patient have for breakfast ?
•Remote : elder brother’s birthday

•Impression :
HIGHER MENTAL FUNCTIONS

• Intelligence :
General knowledge :
Name of the prime minister :
5 states of india :
Name the months in one year:

• Abstraction
Similarities and differences:
• Proverbs :
HIGHER MENTAL FUNCTIONS

• Judgement :

Social : impaired

Personal : impaired

Test :

Letter situation :
Fire situation :
• Insight : Absent
DIAGNOSTIC FORMULATION

• A 21-year-old male ,unmarried , Hindu, from lower socioeconomic status living in

Gurgaon, with nil significant personal and family history. Past history of anxiety
disorder. He presented with 10 days duration of illness which was acute in onset,
had a continuous and course characterized by suspiciousness on family members,
wandering away behaviour , decreased sleep and appetite. On MSE findings ,
Patient was ill- kempt , not dressed appropriately , eye to eye contact was not
established , psychomotor activity was increased, with increased tone of speech,
with irritable affect and with presence of delusion of persecution with impaired
judgement and absent insight.
Differential diagnosis

Acute and transient psychotic disorder

Management

• Patient was admitted to be treated on IPD basis.

• Following investigations were sent :
• Complete blood count
• Liver function test
• Kidney function test
• Blood sugar profile
• Thyroid function test
• ECG
• NCCT Head
• Scale – BPRS (
Clinical course

• Patient was started on

1. Tablet Olanzapine 5 mg the dose of which was increased to 15mg
subsequently
2. Surgery opinion was followed for the treatment of Hemorrhoids.