CL Rounds October 14, 2009
Apr 01, 2015
CL RoundsOctober 14, 2009
General Data•SL•28/M•RH•Married•unemployed•Union Espiritu•Kalinga, Apayao•Admitted Aug 22, 2009 for the first time
in PGH•Informant: patient and wife-good
reliability
Chief complaint:
•Psychiatric complaint: Depression•Orthopedic complaint: B LE weakness
History of Present Illness:
•1 Yr PTA Numbness at bilateral feet with mild
weakness which progressed with sensory loss (-)trauma/fever. Patient was ambulatory but
claimed to have limping gait. There was bowel and bladder incontinence, No consult at this time and no medical intervention.
started to manifest with depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia.
•11 mos PTA:▫Weakness of both feet ascended to both
legs without sensory loss. At this time, the patient had no urine output for 2 days. He then consulted at a local hospital. Folley Catheter was inserted and was sent home. There was no associated fever, hematuria, dysuria.
▫He consulted with a private physician and was given with the Impression SCC. CT Scan was not done due to lack of funds. At this time, the patient was still ambulatory but needed moderate-maximal assist.
• Aug 2009▫consulted at PGH. MRI was done which showed
spinal and epidural soft tissue mass, causing spinal cord stenosis and cord compression patient was then advised surgery hence admission
▫depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia, decreased in intensity after starting treatment in PGH.
▫Patient again started having said symptoms with anhedonia and thoughts of death after he was informed of difficulty securing donors and funds for his operation.
▫Patient is still somehow hoping though that he will be able to walk again, as what his attending physician informed him.
Review of Systems:• (-) fever• (-) headache• (+) weight loss• (+) anorexia• (-)DOB• (-)chest pains• (+) incontinent bowel and
bladder• (+)sweats
Past Medical History
•malaria at 10 y/o•PTB (2006)- incomplete treatment•Hospitalization (2006) secondary to PTB x
10 days•(-) DM/HPN/Heart Dse/Allergy/BA/liver
and kidney dse
Family Medical History
•(+) Cardiac, pulmonary dse•Wife has ANM undiagnosed x 8 yrs•(-) DM/HPN/Heart Dse/Allergy/BA/liver
and kidney dse•(-) same condition
Personal Social History
•Currently a non smoker and non alcoholic beverage drinker, denies illicit drug use
•Patient is currently unemployed•He previously worked as a farmer•His regular diet includes mainly vegetable
and raw fruits•He lives with his wife, 3 children, father
and sister-in-law in a 1 story house with wooden flooring in a studio type nipa hut
Functional History
•Premorbidly independent in all ADLs like grooming
•Min-mod assist in bed mobility and transfers from wheelchair to bed
•Good sitting balance and tolerance•Needs max assist and support from a
stable furniture•Incontinent bowel and bladder
Anamnesis
•Patient is the eldest among 5 living siblings. He was breastfed and had his proper toilet training at age 3.
•As a child, he was active and friendly. He plays with the children around the neighbourhood. And he gets along with his siblings well. He was sickly as a child. But this did not prevent him from making friends or caused any withdrawal from playing and making friends.
•The patient did not go to school and did not have any formal education. As said by his wife, he can’t read or write.
•At 19, he got married. Present has 3 children being 9, 6 and 4 year old. The eldest is being sent to school.
•The patient and his wife are both farmers. They have no problem with the simple life that they have until this present condition where it threatens to tear down the simple happy life that they are most contented with.
• At present, numbness is felt from feet up to waist down. The patient cannot walk and stand without the aid of help. He keeps himself in bed. And occasionally becomes uncooperative. The operation he needs cannot be scheduled without any blood and funds.
• The patient expresses his wish to go home.• Because of the almost 3 months stay in the
ward, resources with time are depleting. This mainly includes food for the bantay, pamasahe going back to the province to seek help and also visit the children and family.
• The patient has no relatives in Manila. So his wife and father stay with him at the wards.
Physical Examination• General Survey: Conscious coherent, oriented
to three spheres and NICRD• BP:110/70 HR: 71 RR:20 afebrile• HEENT
▫PC, AS, (-) TPC, (+) CLAD, (+) anterior neck mass, soft, nodular, non tender moves with deglutition, (-) bruit
• CHEST AND LUNGS▫ECE, CBS, (-)crackles/wheezes
• CVS▫AP, DHS, (-)murmurs
• ABDOMENFlat, NABS, (-) bruit, nontender
Neurologic Examination
•alert, coherent, oriented, NICRD•CN intact
•Motor▫normotonic, fair sitting balance and
tolerance, B UE active and passively done, B LE passively done
▫UE: 5/5▫LE: 3/5
•Sensory▫C2-T6: nosensory impairment to pain and light
touch▫T1-S3: impaired sensation to pan and light
touch
•DTRs▫++ B UE▫+++ B LE
• (+) Babinski• (+) Sustained clonus• (-) Nuchal rigidity
Mental Status Exam•The patient is alert, oriented to three spheres
and cooperative.•The patient is cooperative and attentive,
dressed appropriately according to age and gender, calm with fair eye contact. He showed no odd behaviours. He was smiling most of the time and speaks spontaneously with normoproductive speech and soft voice. He has a broad affect and euthymic. His thoughts were productive and goal oriented.
•He has no memory impairment remote, recent, and past.
•He admits that at the moment, he has thoughts of dying. He has no idea on a specific manner of ending his life, but just the thought and idea of death. He sees death as the only way that would end his sufferings and his family as well. He sees himself as useless and only gives constant problems to his family. He says to himself in his thoughts, if I were dead, maybe I can be of more use because I am not a burden anymore.
• Intact cognition, fair insight, impulse control and judgement
•He has no persecutory delusions, hallucinations.
Assessment
Diagnosis • Axis I: Mood disorder secondary to a general
medical condition vs MDD• Axis II: None• Axis III: Spinal cord injury, incomplete ASIA D, level
T4, prob secondary to potts disease vs metastasis from a thyroid primary
• Axis IV: financial constraint, medical illness, inability to work
• AXIS V: GAF: 61 – 70 (some mild symptoms [depressed mood or mild insomnia] or
some difficulty in social, occupational fnc
Differential diagnosis – AXIS I• Mood
disorder secondary to GMC
• Major depressive disorder
• Adjustment disorder with depressive symptoms
Diagnostic criteria• Prominent and persistent disturbance in
mood characterized by either or both1. Depressed mood or diminished
pleasure or interest2. Elevated, expansive, irritable mood
• Direct physiological consequence of a GMC
• Not accounted by another mental disorder
• Not during a delirium• Sx cause significant impairment in
function
Differential diagnosis – AXIS I• Mood
disorder secondary to GMC
• Major depressive disorder
• Adjustment disorder with depressive symptoms
• Major depressive episode (5 or more)• Depressed mood for most of the day• Diminished interest or pleasure• Significant weight loss• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue or low energy• Feelings of worthlessness
inappropriate guilt• Decreased concentration, ability to
think and indecisiveness• Recurrent thoughts of death
Differential diagnosis – AXIS I• Mood disorder
secondary to GMC
• Major depressive disorder
• Adjustment disorder with depressive symptoms
• Not a mixed episode• Causes significant distress and
impairment in social , occupational and other important functions
• Not a direct physiological effect of a substance or a general medical condition
• Symptoms are not because of bereavement
Differential diagnosis – AXIS I• Mood
disorder secondary to GMC
• Major depressive disorder
• Adjustment disorder with depressive symptoms
• Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within the 3 months of the onset of the stressors
• Symptoms or behaviors are clinically significant as evidenced by ▫ marked distress that is in excess of what
would be expected from the exposure to the stressor
▫ Significant impairment in social or occupational functioning
• Stress related disturbance does not meet the criteria for another axis I or II disorder
• Symptoms not because of bereavement• Symptoms resolve within 6 months
Bereavement
•May present similar to depression•Usually doesn’t involve prolonged feeling
of:WorthlessnessGuiltSelf reproachThoughts of death
Biopsychosocial FormationBiological Factors
Psychological Factors (internal in the patient)
Social Factors (external/ outside world)
Predisposing Factors
Pulmonary TB (2006)
Poor self-esteemLow educational attainmentlack of awareness regarding need for consult
Poor health care system in the area
Precipitating Factors
Spinal Cord Compression
Feeling of worthlessness
Lack of funds
Perpetuating Factors
Progressive weakness, sensory deficit(-) resolution of symptoms
Continued unproductivityThoughts of hopelessness of the condition
Continued delay in surgeryDepletion of resources ( food, fare)
Treatment Goals
•Ensure patient’s safety•Address immediate symptoms and
prospective problems
Treatment Plans
▫Cognitive therapy (expressive – empathic) Address ego regression (damaged self-esteem
and unresolved conflict due to childhood loss or disappointment)
Promote personality change through understanding of past conflicts
Achieve insight to defenses, ego distortions, and superego defects
Provide a role model Permit cathartic release of aggression
Psychosocial Therapy
▫Interpersonal therapy (behavioral – cognitive) Address distorted thinking (dysphoria due to
learned negative views of self, others and the world)
Provide symptomatic relief through alteration of target thoughts
Identify self-destructive cognitions Modify specific erroneous assumptions Promote self-control over thinking patterns
▫Behavior therapy (communicative – environmental) Address impaired interpersonal relationships
(absent or unsatisfactory significant social bonds)
Provide symptomatic relief through solution of current interpersonal problems
Reduce stress involving family or work Improve interpersonal communication skills
▫Family therapy Examine the role of the mood-disordered
member in the overall psychological well-being of the whole family. And the role of the entire family in the maintenance of symptoms.
Pharmacotherapy
▫Patient education regarding the possible side effects of medications and the need for compliance and other drug-drug and drug-food interactions
▫Selective Serotonin Reuptake Inhibitors Effective, easy to use, relative lack of adverse
effects Examples: fluoxetine, paroxetine, sertraline,
venlafaxine, bupropion, etc.
▫Tricyclic Antidepressants Lethal when taken in overdose, cardiotoxic, causes
hypotension, decreased libido, erectile dysfunction, anorgasmia
Examples: amitriptyline, desipramine, imipramine, nortriptyline
▫Monoamine Oxidase Inhibitors Causes serotonin syndrome (hyperthermia, muscle
rigidity and altered mental status) when taken with SSRIs, meperidine and pseudoephedrine, also causes hypertensive crisis when ingested with foods rich in tyramine
Examples: phelzine, tranycypromne
Electroconvulsive therapy:
•used when the patient is unresponsive to pharmacotherapy or cannot tolerate pharmacotherapy or clinical situation is to severe that the rapid improvement seed with ECT is needed
Phototherapy•for those with seasonal mood disorder
Treatment Duration
•When in full remission, maintain treatment for at least 4-6 months in case of first-time episode but longer in recurrent disease
Thank You!
Biological Factors
Psychological Factors (internal in the patient)
Social Factors (external/ outside world)
Predisposing Factors
Pulmonary TB (2006)
Poor self-esteem
Poor health system in the area
Precipitating Factors
Spinal Cord Compression
Feeling of worthlessness
Lack of funds
Perpetuating Factors
Unable to have an operation
Unproductivity Depletion of resources ( food, fare)