Dilla University College of
Medicine and Health Science
Department of Psychiatry
Case Report
Group Members ID no
Milkiyas Tolina……………………………………….4415/18
Bethel Temesgen…………………………………..1021/18
Yewoinhareg Habtamu…………………………..4711/18
Submittion Date : 05/12/2013
Submitted to : Mr. Chalachew Kassa (Bsc,Msc)
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Date : 03/12/2013 E.C
Time : 10:00 LT
Identification
This is Nigussie Zeleke Gashaw, a 19 yrs old unmarried male patient who
come from South region, Sodo. He lives with his family.He is orthodox by
religion and Wolayta by ethnicity. He speaks Amharic and Wolayta language.
He is a grade 11thstudent.This is his 3rd visit, 1st addition and 1st episode. He
was brought by his father and brother forcefully. He was reffered from
Butajira Hospital. He is admitted in 03/12/2013 E.C on the morning.
Currently the patient is in acute male ward 8.Bed no 6. The source of history is
the hisfather. The language of the interview is Amharic. The history is reliable
and adequate.
Chief Compliant : Change in behavior for 2 weeks duration- from father
History of present illness
This is Nigussie Gashaw who was relatively healthy 2 weeks back at which
time he abruptly started to experience behavioral changes like urge to move
both at day and night time, urge to go out, Sleep disturbance, Decreased verbal
communication, Urinary incontinence, refusal to eat, and psychomotor
disturbances like Stillness of upper and lower extremities, difficulty walking,.
One week prior to the onset of the symptoms he had quarrel with his elder
brother;cause he did not do a work related things that his brother told him to
do so then his brother ordered him to leave the house and sleep in the work
place instead. Eventhough, he refused, his brother forced him to leave the
house and slept at the work place for one day. Then the next morning, he went
to the work place late and his brother scolded him for that. Because of this he
was upset and started pulling his hair out of anger. Then his brother saw that
he tried to calm him sleep at the work place anymore.Then the next week the
patient started showing strange behaviours.
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First the patient started to have urge to move both at night and day time with
out any reason. He would just get up out of the blue and would go out and
walk and when his family stop him and ask him where he is going he would
only say ‘‘I want to go” and does not say any thing else. Then he had difficulty
in sleeping at night and he would go out in the middle of the night and would
come back by his own. He falls asleep around 6 o’clock at the midnight and
wakes up at 9 o’clock and he would try to go out so his family lock the door
and would try to keep him inside. Next to this he shows decreased
communication with his family members and he only respond with ‘‘okay” for
every conversations. Then his family took him to holy water where he stayed
for 9 days; but he had no improvement. Then he started having urinary
incontinence. For this reasons he was taken to Butajira Hospital where he was
given Amitriptyline 25 mg po NOCT. Then after starting his medication he
started becoming dizzy and he started sleeping both day and night time. He
took the medication for 4 days and in between he still had urge to move 2
days back, they noticed that he had stiffness of upper and lower extremities
and he had difficulty walking and he also had refusal to eat. And he also
stopped communicating verbally and he would only give his answers by
moving his head slightly. Then he came to AMSH and given Diazepam 5mg po
NOCT and he was appointed after 3 days (PRN injectable) was also given.
Then he went home and only took 1 bite of food and refused to eat and slept
and he have not been awake for the whole day, he was not conscious since he
was admitted to AMSH.
Due to the above symptoms he was unable to communicate with any one, he
doesn’t eat food, he couldn’t keep his personal hygiene, his brother stopped
his work to help him. He has no known Aggravating and Relieving Factors.
Otherwiseas mentioned by his father:
-He has no history of seeing things others can’t see or hearing of things that
others can’t hear.
-He has no history of elevated and expansive mood.
-He has no history of hopelessness, worthlessness and loss of interest.
-He has no history of excessive worryness about the future.
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-He has no history of fear of being in a crowded and public place.
-He has no history of irrational fear of specific object.
-He has no history of witnessing or experiencing stress full life events.
-He has no history of sudden palpitation and bounding heart beat.
-He has no history of deliberate self harm.
-He has no history of trying to harm other people.
-He has no history of substance use.
-He has no history of abnormal sexuality.
SAD PERSONAS
Sex-1 Separated / Divorced /Widowed-0
Age-1 Organized plan-0
Depression-0 No social support-0
Previous attempt-0 Availability of lethal means-0
Ethanol-0 Stated future intent-0
Rational thinking loss-0
TOTAL SCORE= 2 (can be discharged by looking circumstances but we
recommend staying because of the patients situation.)
Past psychiatric history :
He has no history of previous addition and visit
He has no history of mental illness
He has no history of substance use
He has no history of deliberate self harm
He has no history of harming others
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He has no history of domestic violence
Past medical and Surgical history:
He has no history of head trauma and surgery
He Has no history of loss of consciousness and confusion
He Has no history of epilepsy and seizure disorder
He Has no history of chronic medical illness like DM,HTN,HIV/AIDS and
Asthma
He Has no history of Syphilis and Typhoid
Family History :
The patientsparents are both alive and healthy. He had a good relationship
with them. He has 2 brothers and 2 sisters and they all are alive and healthy.
He had a good interaction with all of his siblings. His family are medium in
economical status. They have a good interaction with each other And he was
brought by his Father and his elder brother. His families are very supportive
and concerned about him.
They reported that his aunt from his father’s side has a mental illness and she
has a follow up at AMSH and takes medication regularly. In their family there
is no reported family history of Substance Use, Suicidal attempt, Seizure
disorders, Neurological illness, and Chronic illness.
Personal history :
The patient was born in Sodo. The pregnancy was wanted and there was no
birth complications and the birth was through birth canal.He was breastfed
for two yrs and half and he didn’t have any eating problem. He grew up with
his family and was never away for long time.He started talking at the age of 3
and walking at the age of 2 and 6 months and he didn’t have sleep problem. He
started to use toilet at the age of 2. He didn’t have any temper outburst, no
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thumb sucking and also no bed wetting.He was a playful and active child who
had a good relationship with his playmates.He started school at the age of 8.
He is an average student and he completed 11th grade this year, he has a good
relationship with his class mates and doesn’t participate in gang activities. He
also has a good relationship with his teachers.He didn’t have any learning
disability and also no cerebral dysfunction. He doesn’t have night terrors and
as far as his father knows he doesn’t masturbate and doesn’t use any kind of
substance. He has never had a girl friend and he have no sexual life.
Premorbid history
Premorbid personality trait : the patient was Patient, Not Impulsive, Sociable
He is moderately religious. As the patient’s father explained He wants to work
in Addis Ababa for the future.
Legal history: He has no reported history of being arrested or being
imprisoned in Jail, or being sued.
Mental Status Examination
General Appearance :he was well dressed with clean hospital Pijama and his
face and hair was clean, his nails were short, was sitting on the edge of the bed
and staring on the wall. He doesn’t respond to a painful stimulus.
Attitude towards the Examiner :Poor eye contact, he only stares on the wall,
not cooperative, he doesn’t respond to any questions.
Behavior and psychomotor activity :he was mute, he has waxy flexibility
(he had a resistance when we tried to move his hand and he keeps the
position of his hand on were we placed it meaning he doesn’t regained his
previous position), he has posturing, he has Stupor, but he has no stereotypes,
no mannerism, no tics, no echolalia, no echopraxia.
General Description – He was sitting until we finished interviewing his
parents and he didn’t look perplexed or frightened.
Speech :he didn’t respond when we talked to him
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Mood, Affect ,Thinking and Perception, Sensorium and Cognition are
difficult to assess because the patient was verbally unresponsive.
Physical Examination
General Appearance - sick looking
PR-80 Beats/minRR- 20 B/minTemp- 36.3 oCBP-110/70 SO2-92%
HEENT-Head- the patient have no trauma and scar in his head
Eye-no pre orbital edema
Pink conjunctiva
non icteric sclera
Ear-normal shaped pinna
no discharge
Nose-no discharge
Mouth and throat-no fissure on the lip
the gums are intact, have no bleeding
no extraction of denture or filling
Tongue - the buccal mucosa is pink and wet
Laboratory Investigation :CBC, RBS,OFT, Serum Electrolyte
Case Summary
This is NigussieZelekeGashaw, a 19 yrs old unmarried male patient, who came
forcefully with his father and older brother with a complaintbehavioural
changes for 2 weeks durationof urge to move both at day and night time, urge
to go out, Sleep disturbance, Decreased verbal communication, Urinary
incontinence, Stillness of upper and lower extremities, difficulty walking,
refusal to eat, and score 2 in SAD PERSONAS SCALE and inthe MSE he have
stuper, mutism waxy flexibility, posturing and staring on wall.
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Biopsychosocial formulation
Biological Psychological Social
Predisposing Presence of Conflict with his elder --
family brother
history of
mental
illness
Precipitating -- -- --
Perpetuating -- -- --
Protective Good Good premorbid Good family Support
Physical functionality
Health and
medication
use
Diagnosis :Catatonia 2o ?(the subtype is Retarded Catatonia) (He have 4
symptoms of 12 Catatonic Symptoms, they are Mutism, Waxy flexibility,
Posturing, Stupor.)
Differential Diagnosis:Brief Psychotic disorder with marked
stressor with Catatonia( because he was mute and we couldn’t find any
delusion, hallucination, and disorganized speech to meet the diagnostic
criterion A of Brief Psychotic Disorder but the duration feet.)
Prognosis : Badprognosis because the underlying cause is not known
Management :
-Supportive treatment : prevention of dehydration, good nutritional
suplimentation,frequent vital sign assessment specially temperature because
the patient could be febrile.
-Lorazepam- 2mg IV Bid
-Family therapy- for the problem which happened between the patient and
his brother
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THANK YOU
