Skip to main content

32F reduced sleep and fearful since 5 days

 22/06/2023

Samhita Ghanathay
  • This is an online E log book to discuss our patient's de-identified health data shared after taking her/his guardian's signed informed consent. 
  • Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 
  • This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 











Comments

Post a Comment

Popular posts from this blog

55year old male with SOB and Pedal oedema

15/07/2023 Samhita Ghanathay This is an online E log book to discuss our patient's  de-identified health data shared after taking her/his guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 55 year old male with complaints of shortness of breath and pedal oedema. 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, (History as per date of admission).
Post a Comment
Read more

54 year old male with Fever and Vomiting

21/07/2023 Samhita Ghanathay This is an online E log book to discuss our patient's  de-identified health data shared after taking her/his guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 54 year old male with Fever, Vomitings and Throat pain. 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, (History as per date of admission). CHEIF COMPLAINTS:
Post a Comment
Read more

Medicine Internal Assessment—1 - Review

LONG ANSWERS:  Question number 1:  Define bone density, how is it measured? What are the causes, clinical features,diagnosis and management of osteoporosis? Answer number 1: My answer : Link for the elog case :  https://rishik37.blogspot.com/2021/08/gm-elog-case-7.html Question number 2:  What is myxedema coma? Describe its clinical features , diagnosis and treatment of myxedema coma. Answer number 2: My answer: Link to the elog case : http://mahithguduri63.blogspot.com/2021/09/myxedema-coma.html. Question Number 3: What is the diagnostic approach of young onset hypertension and it’s treatment? Answer Number 3:  My answer: Link to elog : http://keerthykasa80.blogspot.com/2021/09/a-35-year-old-female-with-hypertensive.html Question Number 4:   How do you clinically localize the anatomical level of lesion in spinal cord diseases? Answer Number 4: My answer: Link to elog: http://sowmya9.blogspot.com/2021/08/21-year-old-with.html Question Number 5 : Causes,diagnosis and treatment of atrial
Post a Comment
Read more