August 3, 2017 at 3:37 pm
This a case study by Yahaya, importantly to highlight some of the cardinal symptoms of psychotic disorder and to see peoples contributions.
PATIENT DEMOGRAPHIC DATA
AFE is a 35 year old female who lives at Gwange one opposite Mamman shifta house area of Maiduguri. She is unemployed and Muslim by faith. She is Shuwa Arab and weighs 58kg.
CHIEF COMPLAINT
The patient was admitted in the hospital on the 1st October, with chief complaint of spontaneous and irrational speech which is coherent, laughing for no reason, insomnia and not eating what others have prepared.
HISTORY OF PRESENT COMPLAINT
The patient had been apparently well until about a week before she was admitted in the hospital began to have spontaneous and irrational speech. Prior to onset, she is seen laughing for no reason. Due to the illness, she tends to run away from her husband house in Maiduguri to her parent house in village. She had a history of peptic ulcer disease, loss of weight and fever. No history of associated seizure but however, there is history of seizure in the past and time as mother cannot remember it exactly. No history of behavioral abnormality before or after the seizure.
FAMILY HISTORY
The patient has no any family history of similar symptoms, no family history of diabetes, hypertension or asthma.
SOCIAL HISTORY
The patient is unemployed, 2nd of 4 siblings in a polygamy sitting of 4 wives. No history of cigarette smoking, alcohol intake or any substance abuse.
MEDICAL HISTORY
The patient had history of generalized tonic clonic seizure in the past. She has no known allergy and she is not a hypertensive or diabetic.
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PHYSICAL EXAMINATION
Speech: Spontaneous, irrational.
Affect: mood coherent
Thought: No delusion.
Perception: visual/auditory hallucination
REVEW OF SYSTEM
Cardiovascular: BP 130/80 mmHg.
Pulse rate: 66bpm
ASSESMENT
Bipolar affective disorder current episode mania with psychosis
Schizoaffective disorder??
LAB INVESTIGATION
Tetrahydrocanabinol [THC]………………………………………………………………………………………………………NEGETIVE
Tramadol [TMD]…………………………………………………………………………………………………….NEGETIVE
TCA…………………………………………………………………………………………………………NEGETIVE
Opiate [OPI]………………………………………………………………………………………………………NEGETIVE
Cocaine [COC]………………………………………………………………………………………………………NEGETIVE
Methadone [MTD]……………………………………………………………………………………………………NEGETIVE
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Amphetamine……………………………………………………………………………………………………………….…………..NEGETIVE
Benzodiazepine [BDZ]……………………………………………………………………………………………………………….NEGETIVE
Methyl dioxymethe phelamine [MDMA]……………………………………………………………………………NEGETIVE
PAST MEDICAL HISTORY
Tab. Omeprazole 20mg bd x 2/52
Sus. Relcer gel 10mls tds x 10/7
Tab. Pcm 1g tds x 3/7
Olanzapine 5mg bd
IM haloperidol 5mg start, not >3 doses in 24 hours for aggression.
CURRENT MEDICATION
Tabs haloperidol 5mg bd
Tabs carbamazepine 200mg bd
Tabs benzhexol 2.5 mg am
please comment with the reasons why haloperidol was indicated here and why the dose was tapped?
Good luck.
