CASE P PRESENTATIO TION . Dr C Pradyumna PG in Psychiatry
A case of long standing, untreated, chronic schizophrenia in highly intelligent national chess player from south India.
Name : XXXX Age : 48 years Sex : Male Religion : Hindu Marital status : Separated Residence : Hyderabad Education : B.Sc. Occupation : National chess player Socio-economic status : Lower middle Brought on 5/8/17 to Psychiatric OPD, KIMS Narketpally with his consent by a group of friends (National and International chess players) through PRO of KIMS.
Chief complaints Subjective complaints - No complaints Objective complaints Aimless wandering since 8 years Aggressiveness since 5 to 6 months Talking and muttering to self since 5 months Hearing of voices since 5 months Suspiciousness since 5 months
BACKGROUND HISTORY This case is about one of the most intellectual National group B chess champion who has been separated from his wife and children since more than 20 years. Both parents died and his 2 brothers never wanted to contact or care for him. He continued to stay and wander from one place to another mostly in temples , mosques & gurudwaras . With the support of his friends he would participate in various tournaments and has been a runner since last 2 years in National chess B champion league.
Never visited a psychiatrist previously Poor health and personal care Erratic sleep and appetite were present
HISTORY OF PRESENT ILLNESS: Over a period of last 5 to 6 months his friends observed that his suspiciousness towards them and whosoever approaches him has increased. He refused to tell them where he resides in the city of Hyderabad unlike to his previous self. On closer observation they noticed that he had very poor oral hygiene, wearing shabby and untidy clothes without taking bath for weeks despite on their request and was unnecessarily arguing and talking loudly in threatening attitude to strangers and his chess mates without any apparent reason. Further he revealed that he can communicate with God as he reported that he could hear voice of god.
He used to touch his ears to the walls of the temple and would incessantly kiss the idols of various gods and at times he used to touch the feet of few well adored females visiting the temples. Their were even few incidences where he was slapped by security and managerial persons of temples/gurudwaras Detailed history about his presentation and other symptoms were unknown as he was always resented and parried away if any personal questions were asked regarding his family and past.
However on first of august 2017 , a couple of international masters in chess group of South Indian federation were informed about his condition and after meeting the acquaintances our patient finally agreed for psychiatric consultation However the south Indian chess federation wanted him to get admitted in some inpatient settings for long term treatment because of inability to stay with him by his friends or family members
He used to consume alcohol and tobacco whenever he gets money. On night of 2 nd august they offered him dinner and wine but apparently he drank alcohol in a large quantity and became intoxicated For couple of days he continued to show : Unsteady gait Markedly aggressive and violent tremulousness and slurred speech
No h/o low mood /suicidal ideation / over spending No h/o repeated doing of things /ritualistic activities No h/o restlessness/palpitation/sweating No h/o fever No h/o headache/vomiting/blurring of vision/seizures No h/o head injury.
GENERAL EXAMINATION Patient conscious, oriented. Asthenic built and ill nourished Afebrile . No pallor, icterus, clubbing, cyanosis, lymphadenopathy Vitals - with in normal limits .
SYSTEMIC EXAMINATION Cardiovascular system : S1S2 +, no murmurs Respiratory system : vesicular breath sounds heard B/L Gastrointestinal system : NAD Central nervous system : No focal neurological deficit Fundoscopy : Normal
MSE ON 5/08/2017
Untidy ,unkempt ill groomed Evasive and uncooperative attitude Shouting , arguing and very agitated Talking continuously with rambling speech Contents were at time incoherent and irrelevant Stereotypic motor movements were present Threatening gestures towards doctors and friends Disinhibited behavior present Increased psycho motor activity is seen Rapport was established with difficulty Mood was irritable and incongruent
Formal thought disorder in form of tangentiality, few neologisms, poor word associations and circumstantiality were present Hallucinatory behavior observed as if talking to no mans space as if interacting with deities and spirits ??Visual hallucinations were present Delusion of persecution against few people were present Agreed to play a chess game with consultant of psychiatry in order to communicate with him.
His memory was well preserved Intelligence was good enough in reasoning and high on calculations Concrete level of abstract thinking is present Social and personal judgements were poor but test judgement was normal No insight about his illness.
DI DIAGN GNOSIS CHRONIC LONG STANDING SCHIZOPHRENIA, PARANOID TYPE ALCOHOL INTOXICATION , (UNCOMPLICATED,FIRST EPISODE WITHOUT DELIRIUM)
MANAGEMENT ON DAY 1 Physical investigations like baseline blood investigations CBP LFT RFT SERUM ELECTROLYTES PCV RBS ECG CHEST X RAY USG ABDOMEN were with in normal limits
ACUTE MANAGEMENT: Inj Thiamine 100mg iv in 100 ml NS BID Inj Haloperidol 5mg+Inj Promethazine 25mg im STAT Inj Diazepam 5mg im STAT MAINTANANCE : Tab Carbamazepine 100mg BID ENT & Dental referrals Psychoeducation about the illness to the forum of friends They insisted for admitting him in drug DTC against his will without any family support Discussed pros & cons and difficulties for his inpatient hospitalization in KIMS
Asked them to arrange for regular follow up and was advised to contact the family members of him if possible. Since patient was uncooperative with chronic and long standing psychosis , And there is no one who could supervise his treatment he was put on a test dose of 12.5mg of long acting Inj Fluphenazine decanoate. Base line BPRS score – 76 Planned for further psychometric evaluation
BPRS SCALE:
DAY 14 (19/08/2017) Patient was brought by one of his friend Mild EPS and drooling of saliva ++ Friends tried to contact his family members , his brother refused to answer back and to take any kind of responsibility . Marked reduction in aggressive behavior Reported decreased frequency in auditory hallucinations Suspiciousness reduced, muttering to self++ Sleep , appetite and personal care improved 25mg of long acting Inj fluphenazine decanoate was given 25mg of tablet Amitriptyline 2mg of tab Trihexiphenydyl was added.
FOLLOWUP AFTER 1 month (19/9/2017) Patient came with general secretary of chess association of South India Oral hygiene improved, 50% reduction in drooling of saliva Personal care improved Communication and attitude towards treating team was markedly changed Expressed his gratitude Avoided talks on his delusions and hallucinations BPRS score : 41 (about 50-60% improvement) Wanted to join some job like teaching chess to school students
And was further referred to ASHA REHABLITATION CENTER, HYDERABAD.
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