Psychiatry Presentation
Transcript: DONE BY: SAHIL DAYA PSYCHIATRY PRESENTATION HISTORY HISTORY DEMOGRAPHIC DATA MR BM 26 YEAR OLD MALE FROM HORISON PARK LIVES WITH HIS SISTER, PARENTS RESIDE IN THE FREE STATE SINGLE, NO CHILDREN HIGHEST LEVEL OF EDUCATION ACHIEVED: GRADE 12 CURRENTLY UNEMPLOYED, ATTEMPTING TO UPGRADE HIS MATRIC RESULTS CHRISTIAN NOT A KNOWN MHCU BROUGHT TO HOSPITAL BY HIS SISTER WITH INDEX EPISODE OF HALLUCINATING, SPEAKING TO HIMSELF AND AGGRESSIVE BEHAVIOUR SYSTEMATIC ENQUIRY SYSTEMATIC ENQUIRY PSYCHOTIC DELUSIONS GRANDIOSE DELUSIONS- PATIENT BELIEVES THAT HE HAS THE ABILITY TO MANUFACTURE ANYTHING AND IS A GREAT SCIENTIST AND INVENTOR. HE REPORTS HAVING INVENTED A "BENCH" WHICH GIVES YOU THE BEST WORKOUT IN THE WORLD AND CAN MAKE ANYONE AN EXPERT SOCCER PLAYER. HE ALSO BELIEVES THAT HE IS THE DESCENDANT OF UMKHONTO WE SIZWE AND KING KENNETH KAUNDA. PATIENT REPORTS THAT HE IS HIGHLY INTELLIGENT AND GIFTED AND WAS SUPPOSE TO STUDY SCIENCE, BUT INSTEAD HE IS STUDYING MARKETING AT UNISA (COLLATERAL FROM SISTER: PATIENT PERFORMED VERY POORLY AT SCHOOL AND BARELY PASSED MATRIC AFTER FAILING MULTIPLE TIMES, HE DOES NOT STUDY AT UNISA). PSYCHOTIC CLUSTER PERSECUTORY DELUSIONS- THE PATIENT HAD PERSECUTORY DELUSIONS TOWARD HIS SISTER, BELIEIVNG THAT HIS SISTER WAS JEALOUS OF HIM AND HIS TALENTS AND WAS TRYING TO SABOTAGE HIM. HE ALSO BELIEVED THAT HIS SISTER'S FRIEND WAS TRYING TO TAKE OVER THEIR HOUSE AND WAS TRYING TO INFLUENCE BOTH HIM AND HIS SISTER TO FOLLOW "THE WRONG PATH". HE SUSPECTS HIS SISTERS FRIEND OF STEALING HIS FATHER'S PROJECTOR. HE BELIEVES THAT HIS FATHER HATES HIM AND WANTS TO CONTROL EVERY ASPECT OF HIS LIFE BY FORCING HIM TO STUDY MARKETING AND NOT FOLLOWING HIS PASSION FOR SCIENCE. HIS FATHER ALSO PUNISHED HIM BY MAKING HIS SISTER "THE MAN OF THE HOUSE". BIZARRE DELUSIONS- THE PATIENT BELIEVES THAT HIS THREE DOGS HAVE BEEN POSSESSED BY WITCHES AND IN ORDER TO FREE THEM FROM THE WITCHES HE HAS TO SPIT ON THEM AND IN THEIR MOUTHS. HE ALSO BELIEVES THAT HIS SISTER IS THE BOSS OF WESTGATE. NO SOMATIC, NIHILISTIC OR RELIGIOUS DELUSIONS WERE ELICITED, NEITHER ANY DELUSIONS OF REFERENCE HALLUCINATIONS PATIENT DENIED HAVING ANY AUDITORY, VISUAL, OLFACTORY OR TACTILE HALLUCINATIONS. PASSIVITY PHENOMENA NO EVIDENCE OF THOUGHT INSERTION, DELETION, CONTROL, BROADCASTING OR WITHDRAWAL NEGATIVE SYMPTOMS NOT ELICITED MOOD PATIENT WAS NOTED TO HAVE A HIGH MOOD AND WAS VERY TALKATIVE. HE APPEARED TO HAVE GOAL-DIRECTED ACTIVITY, HE SAID THAT HE HAD NO TIME TO BE IN HOSPITAL AS HE HAD MANY THINGS TO DO AND HE HAD TO GO BACK TO HIS STUDIES AND HIS WORK AS A SCIENTIST. HE WAS CARRYING HIS ACADEMIC PORTFOLIO AROUND WITH HIM. NEUROVEGETATIVE FEATURES HE SAID THAT HE SLEEPS WELL (COLLATERAL: PATIENT WANDERS AROUND THE HOUSE AT NIGHT AND DOES NOT SLEEP) HE REPORTED HAVING AN INCREASED LEVEL OF ENERGY NO CHANGES IN APPETITE OR LIBIDO MOOD CLUSTER COGNITIVE FEATURES PATIENT HAD POOR CONCENTRATION AND WOULD OFTEN GET DISTRACTED THROUGHOUT THE INTERVIEW NO CHANGES IN MEMORY ELICITED NO FEELINGS OF GUILT OR RUMINATION NORMAL THOUGHT SPEED PHYSICAL FEATURES NIL ELICITED SUICIDAL IDEATION NIL CURRENT OR PAST ATTEMPTS AT SUICIDE NO FUTURE PLANS OR INTENT ANXIETY NO HISTORY OF PANIC ATTACKS OR GENERALISED ANXIETY NO OBSESSIONS OR COMPULSIONS ELICITED NO HISTORY OF A TRAUMATIC EVENT, OR ANY FEATURES OF POST TRAUMATIC STRESS DISORDER NO SPECIFIC PHOBIAS ANXIETY CLUSTER ICTAL NO HISTORY OF SEIZURES, LOSS OF CONSCIOUSNESS NO PERCEPTUAL DISTURBANCES SUCH AS MICROPSIA, MACROPSIA OR DYSMEGALOPSIA NO HALLUCINATIONS, ILLUSIONS NO MEMORY DISTURBANCES SUCH ASDEJA VU, JAMAIS VU, PREMONITIONS NO DISSOCIATIVE STATES (DEPERSONALISATION, FUGUE STATES) ICTAL CLUSTER EATING DISORDER NO EVIDENCE OF FOOD RESTRICTION, BINGING, PURGING OR VOMITING NO EVIDENCE OF FOOD RESTRICTION NO DISTURBANCES IN BODY IMAGE, WEIGHT ELLICITED EATING DISORDER CLUSTER PAST PSYCH HISTORY THIS IS THE PATIENT'S INDEX PRESENTATION TO HOSPITAL ACCORDING TO FAMILY, THE BIZARRE BEHAVIOUR BEGAN IN JULY 2019, AND HAD SIGNIFICANTLY WORSENED LATELY THE PATIENT IS UNABLE TO LIVE A PRODUCTIVE LIFE BECAUSE OF THE ILLNESS AND IS CURRENTLY UNEMPLOYED AND NOT STUDYING AS THIS IS THE INDEX PRESENTATION, NO DIAGNOSES OR TREATMENT HAVE BEEN GIVEN TO THE PATIENT PAST PSYCHIATRIC HISTORY FAMILY PSYCH HISTORY PATERNAL GRANDMOTHER REPORTEDLY HAD BIZARRE BEHAVIOUR AS WELL AS MAGICL THINKING. SHE WAS NEVER DIAGNOSED WITH A MENTAL ILLNESS NOR TOOK ANY TREATMENT. NO OTHER FAMILY PSYCHIATRIC HISTORY REPORTED. NO HISTORY OF SUICIDE BY ANY FAMILY MEMBERS. FAMILY PSYCHIATRIC HISTORY MED AND SURG HISTORY MEDICAL HISTORY PATIENT HAS NO KNOWN MEDICAL COMORBIDITIES. DOES NOT USE ANY CHRONIC MEDICATIONS. SURGICAL HISTORY NIL OF NOTE. MEDICAL AND SURGICAL HISTORY SUBSTANCE USE AND FORENSIC HISTORY SUBSTANCE USE PATIENT IS A NON-USER OF ALCOHOL OR TOBACCO PRODUCTS. HE STARTED USING CANNABIS DURING HIGH SCHOOL, AND CONTINUES ABUSING THE DRUG. HE ADMITS TO USING CANNABIS 2-3 TIMES DAILY. HE DOES NOT USE ANY OTHER ILLICIT
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