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L.M.P., a 35 year-old married Born Again Christian who lives in Bacoor, Cavite

L.M.P., a 35 year-old married Born Again Christian who lives in Bacoor, Cavite. CHIEF COMPLAINT (Patient): “Hindi ako nakakatulog, hindi ako nakakakain at huminto kasi akong uminom ng gamot.” (Sister-in-Law): “Nagsasalita ng kung anu-ano.”. PERSONALITY PROFILE Premorbid Personality:

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L.M.P., a 35 year-old married Born Again Christian who lives in Bacoor, Cavite

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  1. L.M.P., a 35 year-old married Born Again Christian who lives in Bacoor, Cavite

  2. CHIEF COMPLAINT (Patient): “Hindi ako nakakatulog, hindi ako nakakakain at huminto kasi akong uminom ng gamot.” (Sister-in-Law): “Nagsasalita ng kung anu-ano.”

  3. PERSONALITY PROFILE Premorbid Personality: “masinop, masayahin, sensitive” Morbid Personality: “tahimik, kung ano-anong sinasabi”

  4. SOURCE AND RELIABILITY Patient: 75% Sister-in-Law: 85%

  5. HISTORY OF PRESENT ILLNESS December 2004 increased preoccupation with religion January 2005 more intense preoccupation with religion quiet and overtly sensitive believed that members of her church group were against her

  6. February 2005 God’s voice was “telling” her to do something lost appetite reduced amount of sleep 1st week of March 2005 blank stares anxiety God “communicated” with her

  7. 3rd week of March 2005 unusually quiet barely did household chores 4th week of March 2005 felt something bad will happen to family shouted at church members asked forgiveness commented on bystanders something was “plotting” against them speaking in tongues hyperventilating

  8. 1st week of April 2005 continued to be suspicious of her surroundings told her relatives not to worship idols 2nd week of April 2005 saw “strange people” would not come out of van irritable and shouted at relatives 10-day stay at USTH-CC “maldita” and “matigas ang ulo” Tx: Quetiapine 100 mg AM, 200 mg PM Clonazepam, ¼ tab

  9. 3rd week of May 2005 Quetiapine 100 mg AM was discontinued Patient refused to take medication June 2005 resistive, hyper, violent Given diphenhydramine 25 mg IM and Haloperidol 5 mg IM ADMISSION

  10. REVIEW OF SYSTEMS • No headache, loss of consciousness or convulsions • No fever • (+) anorexia and weight loss • No cough or colds, no dyspnea • No chest pain, no easy fatigability • No change in bowel or bladder habits • No bleeding tendencies

  11. PAST MEDICAL HISTORY • Not known hypertensive, diabetic or epileptic • No previous hospitalization or operation

  12. FAMILY HISTORY • (+ dependence) HPN – mother • (+) stroke – mother • (+) heart disease, PUD – father • (+) alcohol dependence – father • (?) nervous breakdown – great grandmother

  13. PERSONAL HISTORY • She is a non-smoker and non-alcoholic beverage drinker • She denies use of any prohibited substance

  14. ANAMNESIS

  15. PRENATAL AND PERINATAL HISTORY • NSD at home with • Neurodevelopmental milestones were at par with age.

  16. EARLY-MIDDLE CHILDHOOD • Lived with parents and three siblings • Left in the care of the father, an alcoholic • Father had occasional fights with his wife • Patient admits his father had his “weaknesses” but was very affectionate and loving

  17. EARLY-MIDDLE CHILDHOOD • Mother strict and disciplinary • Mother and father occasionally fight • Grew up closer to her father

  18. MIDDLE CHILDHOOD • Primary education at Malubog-lubog Elementary School in Capiz • Average student and had very few friends • 6th grade - father died which caused extreme sadness • Left in the care of the eldest sibling

  19. ADOLESCENCE • Family Relationship • after father’s death, mother married a policeman • Siblings were against the marriage • had a harmonious relationship with stepfather and stepsiblings • Stepfather was kind and approachable but was not able to fill the void left by her father

  20. ADOLESCENCE • Social Relationships • Had a number of friends • stayed at home on weekends • School History • Wanted to take up AB Philosophy • forced by mother to take up BS Nursing • Graduated on time

  21. ADOLESCENCE • Academic Achievement • failed Nursing Board Exams • failure due to “poor preparation” • had guilt feelings

  22. YOUNG ADULTHOOD • 1993 - nurse in Capiz and resigned after 6 months • Patient was pious and hardworking • Gave portion of salary to patients • Also worked in a government hospital in Capiz and resigned as to the request of elder sister

  23. YOUNG ADULTHOOD • Meaningful Long term relationship - did not have serious relationships - 1994 - met Norman and married him after two years - Stayed with husband’s family - Got pregnant and went back to Capiz - 1997 – CSD with her 1st child

  24. YOUNG ADULTHOOD • 1998 – went to Abu Dhabi with husband and had no difficulty in adjusting • 1999 – decided to return to Manila due to 2nd pregnancy • 2000 – gave birth to second child • Stayed with her mother, who sometimes helped out with her grandchildren • Longed for her husband

  25. YOUNG ADULTHOOD • 2001 – returned to UAE because of argument with mother • Was baptized to a Born-Again Christian group • Got pregnant with her 3rd child

  26. YOUNG ADULTHOOD • Work Experience • First worked as an assistant nurse • Very little compensation while waiting for the next board exams • resigned to take 2nd board exam • Worked as Ticketing supervisor and resigned after 2 mos • Petition by her maternal aunt was declined by the German Embassy

  27. WORK EXPERIENCE • 1998 - sales clerk in a pharmacy in Abu Dhabi • 1999 - resigned because of 2nd pregnancy • No difficulty adapting to new environment • No difficulty adjusting to new role as mother

  28. FAMILY PROFILE

  29. LEGEND Heart attack Stroke Cesar 45 Minerva 58 Ricardo 60 4 1996 Leicel 35 Norman 38 Julius 33 Gina 38 5 2 Paul Christopher 8 Patricia Louis 5 Tim Albert 2

  30. PHYSICAL EXAMINATION • General Survey - Conscious, coherent, not in cardio-respiratory distress, ambulatory • Vital Signs BP: 115/80 PR/CR: 90/min regular RR: 18 cpm Temp: 37.1°C • Skin - Warm, moist skin, no active dermatoses

  31. PHYSICAL EXAMINATION • EENT - Pink palpebral conjunctivae, anicteric sclerae - No naso-aural discharge, nasal septum midline - Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged • Neck -supple neck, no palpable cervical lymph nodes, no anterior neck mass

  32. PHYSICAL EXAMINATION • Respiratory - Symmetrical chest expansion, no retractions, clear breath sounds • Cardiovascular - Adynamic precordium, AB 5th LICS, MCL, no murmurs • Gastrointestinal - Flat abdomen with NABS, soft, non tender, no organomegaly - Warm, moist skin, no active dermatoses

  33. PHYSICAL EXAMINATION • Extremities - No cyanosis, no clubbing, no edema • Peripheral Vascular - Pulses are full and equal

  34. NEUROLOGICAL EXAMINATION • Conscious, coherent, oriented to time, place and person • Intact remote, recent and immediate memory • Cranial Nerves: - Pupils 2-3mm ERTL, (+) direct and consensual light reflex - Fundoscopy: (+) ROR, clear media, distinct disc margins, C/D ratio 0.3, AV ratio 2:3

  35. NEUROLOGICAL EXAMINATION • Cranial Nerves: - No visual field cuts - EOMs full and equal - Can clench teeth, no facial sensory deficit - No facial asymmetry, can raise both eyebrows, can smile, can purse lips - (+) gag reflex, uvula midline on phonation - Can shrug shoulders against resistance - Tongue midline on protrusion

  36. NEUROLOGICAL EXAMINATION • MMT no atrophy, no fasciculations, normal muscle tone • 5/5 in all extremities • Can do APST and FTNT with ease • DTR: ++ in all extremities • (-) Babinski reflex, no frontal release signs • No sensory deficits • No nuchal rigidity

  37. Mental Status Examination on Admission • Awake but agitated • Well kempt wearing T-shirt and pants • Speech was modulated but repetitive words were spoken • Good eye contact but inattentive when interviewed • Had preoccupation in getting out the Community Center • Oriented to time, place and person • Affect: appropriate • Anxious and uncooperative • Other examinations not performed – Px uncooperative

  38. SALIENT FEATURES • MSE: • Awake and agitated • Modulated speech with verbigeration • Inattentiveness • Oriented to time, place and person • Appropriate affect • Anxious and uncooperative • 35 y/o / Female • Born again Christian • Unemployed • preoccupation with at least 2 delusions (Jan-Apr 2005) • Bizaare aggressive/agitated behavior (Apr & June 2005) • Avolition-apathy (3rd wk & 27 Mar)

  39. DSM-IV TR Criteria for Schizophrenia A. Characteristic Symptoms • 2 or more of the ff during a 1-month period. 1. Delusions 2. Hallucinations 3. disorganized speech 4. grossly disorganized or catatonic behavior 5. Negative symptoms (affective flattening, alogia or avolition) Note: Only one symptom is required if delusion is bizarre or hallucinations consist of a voice keeping up a running commentary on the persons behavior or thoughts, or 2 or more voices conversing with each other.

  40. DSM-IV TR Criteria for Schizophrenia • B. Social/Occupational Dysfunction • in 1 or more areas of functioning • work • interpersonal relationship • self-care

  41. DSM-IV TR Criteria for Schizophrenia • C. Duration • continous signs for atleast 6 months that must include: • 1 month of active symptoms (or < if succesfully treated) • ± periods of prodromal or residual symptoms • only negative symptoms • 2 or more Criteria A symptoms in attenuated form (eg. Odd beliefs, unusual perceptual experience

  42. DSM-IV TR Criteria for Schizophrenia • D. Schizoaffective and mood disorder exclusion: 1. No major depressive, manic, or mixed episodes concurrently during active symptoms. 2. If mood episodes have occurred during active-phase symptoms: • duration of : mood disorders < active and (brief) residual periods

  43. DSM-IV TR Criteria for Schizophrenia • E. Substance/ General medical condition exclusion • disturbance NOT due to: • a substance ( illicit drug , medication) • general medical condition

  44. DSM-IV TR Criteria for Schizophrenia • F. Relationship to a pervasive developmental disorder: • w/ Hx of autistic disorder, pervasive developmental disorder • additional dx of schizophrenia be made only if prominent delusions or hallucinations are present for atleast 1 month.(or < if successfully treated)

  45. DSM-IV TR Criteria for Schizophrenia • Classification of Longitudinal Course • can be applied ONLY AFTER at least 1 year since the initial onset of active-phase symptoms.

  46. DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPES PARANOID TYPE • Preoccupation with one or more delusions or frequent auditory hallucinations • No prominent s/s of disorganized type DISORGANIZED TYPE Prominent: 1. Disorganized Speech 2. Disorganized Behavior 3. Flat / Inappropriate Affect

  47. CATATONIC TYPE At least two of the following: 1. Motoric Immobility - Catalepsy or Stupor 2. Excessive motor activity - purposeless,not influenced by external stimuli 3. Extreme Negativism 4. Posturing • RESIDUAL TYPE • Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized, or catatonic behavior • Continuing evidence of disturbance • -negative symptoms in attenuated form UNDIFFERENTIATED TYPEmeet Criteria A but not for the paranoid, disorganized or catatonic type.

  48. DSM - IV Diagnosis • Axis I: Schizophrenia, paranoid type • Axis II: none • Axis III: none • Axis IV: psychosocial problems • Axis V: GAF: 20 - some danger of hurting others

  49. ICD-10 Diagnostic Criteria for Schizophrenia

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