22/06/2023
Samhita Ghanathay
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32 year old female with complaints of reduced sleep and fearfulness
I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.
Following is a brief about the case.
CHIEF COMPLAINTS:
32 year old female, resident of Janagam, homemaker by occupation came to psychiatry OPD with complaints of:
- Reduced need for sleep since 5 days
- Fearfulness since 3 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 10 days ago, when she had an argument with her husband (reason not willing to mention) she started being worried about her family.
Since 5 days she is getting up earlier than usual and doing housework to keep herself distracted.
Since 3 days, she is fearful and getting thoughts about past events and has increased libido.
PAST HISTORY:
Patient has a history of similar complaints in the past.
She was reported to be fine between the events.
In 2015, 1.5 months after birth of 2nd child, she didn’t sleep for 7 days - she found herself staring at walls through the night; during the day, her family noticed she read the Bible all day, started crying for small things and did not take care of the baby.
Following this, she was taken to a psychiatrist(no reports available) and was on medications for 3 months after which she stopped the medication and maintained well for almost 3-4 years.
After that, family issues like loss in business triggered her symptoms and the condition relapsed. During this time, she faced fearfulness and crying spells, with reduced sleep, but took care of the baby.
In 2020, she thought Corona came because of her.
Often her family found her smiling at herself or lost in thoughts.
She complained of hearing random anklet sounds and feared someone might kill her, so tried to kill herself by medicine overdose (medicine not available). She was taken to the hospital and consulted with 2 psychiatrists, but the symptoms did not subside.
Medications used -
- T. PAROXETINE 12.5mg
- T. PROPRANOLOL 20 + CLONAZEPAM 0.25mg
- T. OLANZAPINE 2.5 mg
Then she reported 70% improvement.
Later wasn’t compliant with the medication.
No history of surgery in the past.
Not a known case of DM, HTN, TB, Asthma, Epilepsy.
PERSONAL HISTORY:
- Diet - mixed
- Appetite- normal
- Bowel and bladder - regular
- Sleep - reduced
- Allergy- no known allergies
- Addiction- occasional toddy consumption.
- Menstrual cycle - regular.
FAMILY HISTORY:
No complaints of similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Moderately built and nourished.
Her consent is taken.
She is examined in a well lit room after adequate exposure.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
VITALS:
- Temperature- afebrile
- Respiratory rate - 19 cpm
- Pulse rate - 72bpm
- Blood pressure - 130/90 mm Hg
SYSTEMIC EXAMINATION :
* CNS -
-Normal sensory and motor systems.
* Respiratory system -
-Bilateral air entry present.
-Normal vesicular breath sounds heard.
* CVS -
- S1 and S2 heard
- murmur - absent
* Abdomen -
-Soft and non tender.
INVESTIGATIONS:
- CBP - low Hb - 10.1
- CUE - Normal
- RBS - normal
- LFT
- Serum creatinine:
- Blood urea:
- Serum electrolytes:
- ECG : No significant changes.
PROVISIONAL DIAGNOSIS:
Schizophrenia
TREATMENT:
- T. PROPRANOLOL 20mg
- T. RESPERIDONE 2mg + T. THP 2mg
- T. CLONAZEPAM 0.5mg
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