CASE PRESENTATION

CHAIRPERSON PRESENTED BY
Mr. Sujit Ruchika Sharma
Mr. A, 20 years old unmarried male, studying in 3rd year of BCA, belonging to a
Hindu nuclear family of middle socio-economic status, residing in urban area of
New Delhi.

Informants:
• Patient
• Parents (mother and father)
Information:
• Appears to be adequate and reliable
• The total duration of illness – 6months
• Insidious onset, progressive nature and continuous course

• Precipitating factors: None

Chief complaints:

According to patient:
• Mere peeche kuch log pade huye hain jo mujhe nuksan pahuncha rahe
hain(from 6months)
• Mujhe or mere parents ki jaan ko khatra hai(from 6months)

According to informant:
• Shaq krta hai (from 6months)
• Ajeeb ajeeb batein krta hai (from 6months)
• Do din se ghar me mar pitayi kar rha hai (since 2 days)
History of the present illness

Mr. A was apparently doing well 6 months back. He was going to his
college regularly and was behaving well with his family members. He
was having regular meals and adequate sleep. In the month of May
2018, the patient’s family members noticed that he would remain
disturbed after coming back from college.
On being asked he would tell them that there are some friends who
would take notes from him and his practical books on the pretext of
needing his help with their studies but they want to irritate him and
annoy him by doing so. He would tell his parents that they would take
his notes so that he would not be able to study properly. He told them
that earlier also they would ask for his notes but that would be
occasional however, now it has increased in frequency and they are
purposely doing so to irritate him and hamper his studies.
The patient’s family members would try to console him and told him
that he should not pay attention to such things as its normal for
students to ask for notes from each other and if he does not want to
give notes to them he could simply say no. Over the next few weeks the
patient continued reporting these beliefs to his mother and told her
that his friends would ask him to send them pics from his books and to
photocopy the books and notes to give to them. The patient also
started reporting to his mother that all his friends would consider him
inferior to them and would make fun of his appearance.
As per the patient they would sit behind in the class and would mock
him, call out his name and would comment on his personality. His
parents told him that he should focus on his studies and if those
students are annoying him then he could simply avoid having any
conversation with them and not to pay any attention to them. During
this period the patient was having normal conversation with his family
members and his self-care was also proper. He was also having regular
meals and adequate sleep.
This behavior of the patient continued for another 4 months. During

these four months though he was going to college regularly, he would

remain disturbed after coming back from there. He would tell his

parents that his friends have done black magic on him and know

everything about him and his family members in detail.

As per the parents he would stay in room during this period and would
study for most of the day. He would also help his mother in other
household work and would have regular meals and adequate sleep.
Whenever, his parents would ask him to go to college he would deny
them starting that he would go directly to give exams which were due
in November. For the past 7 days the patient started complaining to his
mother about his maid that she does the black magic and harm the
family members.
He also reported that there is ghost in the house. The patient became
aggressive and tried to run away from home and starting hitting the
family members. His parents then took the patient to IBHAS in
September 2018. The patient was given Lorazepam 2mg , Risperidone
2mg. Patient became violent and hitting the family members. Family
members decided to bring him to VIMHANS on 17th November, 2018.
Following admission, the patient was on olanzapine 10mg.
Negative History
• No history of taking another substance of abuse.
• No h/o elated mood, increased energy, flight of
ideas and optimistic view of the future.
• No history of thoughts being taken away from the
mind by an external agency, thoughts being
inserted or thoughts being spoken aloud
• No history suggestive of disturbances in
perceptual modalities like vision, taste, smell,
touch etc.
• No history of own thoughts being repetitive,
intrusive, irrational and distressing to the patient.
 Previous
Risperidone Trihexyphenidyl Clonazepam 1
Treatment 2mg 2mg mg
History:
 Mr. A belongs to middle socio-economic status
Hindu nuclear family. His father is govt employee
and mother is a home maker. He has one elder
sister and one younger sister. Both sisters have
Family History:
been diagnosed with mental retardation. There is
no history of any psychiatric disorder. Parents
having adequate understanding about patient’s
illness.
 Father Mother

sister Patient Sister

Mental Retardation 20 years Mental Retardation
 Childhood history- Patient had a
Birth and early childhood- good interaction with his peer
Patient was a full term normal group. There has been no history
delivery with normal birth weight. of thumb sucking, nail biting and
Academic history- Mr A was good
Birth cry was immediate. There head banging; no history
in academics and scored 84% in
was no pre or post- natal suggestive of severe temper
Personal History: 10th and 75% in12th. He is
currently pursuing BCA from
complications reported. tantrums, angry or resentful
Developmental milestones were behavior; no history of physically
Amity University.
achieved in time. No significant harming others, destroying others
history of physical illness during property or stealing; no history of
childhood. inattention, hyperactivity and
impulsivity.
Pre-morbid Personality :
The patient’s predominant mood was cheerful and was optimistic
about the future. He had a small group of friends who he was close to.
He preferred to spend time with his small group rather than going out.
He had a cordial relationship with his friends and relatives. He enjoyed
studying.
Patient was responsible towards his work commitments. He would
welcome responsibility given to him. He had no problems in making
decisions with respect to his work as well as his family.
He used to be a calm person and would stay cheerful most of the time.
Impression: well adjusted
Mental Status Examination

(The patient was admitted to VIMHANS on 18th December 2018, the MSE
was taken on 11th January 2019)

General Appearance and Behaviour: A young adult male sat on the chair
facing the interviewer and greeted her. He appeared to be in touch with his
surroundings. He was appropriately dressed. Overall, patients’ attitude
towards the examiner was cordial, he maintained eye contact, and a working
rapport was established. He was conscious, cooperative and communicative.
Psychomotor activity
The patient’s motor activity is normal.

Speech: the patient’s speech was coherent, relevant and goal-directed.

• rate/ quantity of speech: Average

• tone/ volume: Average
• Reaction time: Average
• Mood:
Subjective: Mann kaisa hai?
Mann bhut preshan hai, muje mere dost se bcha lo
Objective: fearful

• Affect:
Range was full
Reactivity was present
Congruent to thought content
Appropriate to situation
Thought:
• Content:
Muje bcha lijiye. Mere dost muje mar dalege, unhe black magic ata hai.
Meri her activity par najar rkhte hai.
• Inference: delusion of persecution
Perception: no perceptual abnormalities could be elicited.
Cognitive function:
• Oriented to time, place and person
• Attention and concentration
• Digit span test-forward 5
Backward 3
Memory:

Immediate – repeat these 3 words: pen, chair, flag

Recent- breakfast kya kiya
Remote- birthday of his mother

Inference- immediate, recent and remote memory intact

Intelligence:
Q. Who is the P.M. of India?
A. Narendra Modi
Q. Name 5 cities in India
A. Delhi, Bombay, Calcutta, Chennai , Hyderabad
Q. Name 5 rivers in India
A. Ganga, Yamuna, Sarasvati, Godavari and Narmada

Inference: General fund of knowledge was adequate.

Abstract:
• Similarities:
Orange & apple: Dono fruits hain
Dog & elephant: Dono animal hain
Table & chair: Dono wood kae hai
• Proverbs:
Bander kya jane adrak ka swad: “jisko jis bare main jaankari nahi hai
woh kya bolega”
Kaala akshar bhains barabar: “murkh ko kitna bhi samjha lo wo murk hi
rahata hai”

Inference: intact
Judgment:
Personal: “aage kya krna chahte ho?”
Aap bs muje bcha lijiye. Kuch smhjh nhi aa rha kya kru kya nhi.
personal: impaired
Test:
Envelope test: jiska hai usko de duga
Fire test: fire brigade ko bulaunga

Inferences: personal judgement impaired, test judgement intact

Insight grade-1

Diagnostic Formulation

A 20 year old unmarried Hindu male, living in a nuclear family, belonging

to middle socio economic strata, pursuing BCA, residing in the urban
domicile of Delhi, well-adjusted pre-morbid personality presented with
complaints aggression, persecution since past 6month. On MSE, the
patient was oriented to time, place and person. Patient has delusion of
persecution, fearfulness , personal judgement is impaired.
• Diagnostic Impression:
ICD 10, F20.0

According to book symptoms are :

Delusion
Hallucination
Excitement or Agitation
Hostility or aggressive behaviour
Suspiciousness, ideas of reference
Possible suicidal tendencies
Patient’s symptoms are: (since 6months)
• Anger
• Aggression
• Fearfulness
• Delusion of persecution
• suspiciousness
Risperidone 2mg

Clonazepam 2mg

Olanzapine 10mg

Trihexyphenidyl
2mg
 Therapies

Art and
craft PVA and
therapy cognition

Music
Therapy Group
discussion
 Nursing Diagnosis

Social isolation related to

Disturbed thought process, Ineffective health maintenance
inability to trust, delusional
related to inability to trust as related to inability to trust,
thinking as evidenced by
evidenced by extreme extreme suspiciousness
withdrawal, sad, or expression of
suspiciousness or delusional evidenced by poor diet intake
feelings of rejection of aloneness
thinking. and difficulty in falling asleep.
imposed by others.
 Nursing Management

Identify with client symptoms he/she Guide the client in identifying

experiences when he/she begins to activities that help reduce his/her
feel anxious around others. anxiety

Make conversations simple, basic Involve the client in reality-based

and reality-based activities such as drawing or listening
to music
 Remember to give praise
Encourage the client to or recognition for
use coping skills positive steps the client
particularly takes in increasing social
conversational skills

Discuss clearly with the

client’s family the course
of treatment