Case

Problem Based Learning Part I

Set by: Jerman .D (BSc, MSc in clinical psychiatry)

11/05/24 Jerman .D 1
 ID
• Mr. Getachew Adugna is a 35 years old, married
, male patient ,whose ethnicity is oromo , and his
mother tongue is Afan Oromo. He is follower of
orthodox church . He was previously a farmer
but hasn’t worked for the last 4 months due to
his illness. He used to live in Ambo with his
family.He is educated up to grade 3. He was
brought by his Father with this being his 1st
episode with first visit to Amanuel hospital.

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The information was taken from both the
patient and his attendant by Afan
oromo ,without any translation.

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 Chief complaint
• From the pt : sleep disturbance
• From collateral: urge to go out for the duration of 1 month

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 Discussion Questions
1. List /summarize sign and symptoms based on Patient’s
history(hx) and MSE…..Group 1
2. Identify etiology /risk factors of the disorders on the basis of Hx
and MSE…. Group 2
3. List differential diagnosis(ddx) and put the correct diagnosis as
per history (hx) and MSE… Group 3
4. What is/are the pharmacological and psychological treatment
for z patient? ….Group 4
5. Identify predictors of good/bad outcome and prognostic factors
based pt’s problem…. Group 5

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 HPI
• This patient was relatively healthy around 1 yrs
back after which he gradually start to experience
symptoms like sleep problem manifested by inablity
to initiate sleep most of the time and awake all night
and start to feel the frequent urge to go out of home
without any reason or knowing where to go , even
he never get back on his own, his family reach for
him and return him home.
• He became irritable as his father reported and he
destruct materials like door and windows, when his
family ask what his problem is ? but the patient deny
about the irritable issue and also destructing
material.
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• He also remove his cloth and go out with naked
body ,as a reason the patient say I don’t know why I
did that , one day he tried to burn the house that
they used to live and when asked why? He replied I
just burn the pill of grass which is not useful, not the
house.
• In addition to this, the pt has poor personal hygiene
not taking care of him self , not washed his body, his
leg and face the patient said I just don’t feel like to
wash

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• Without any external stimuli he heard voice which is
young male voice but the patient has no response for
the voice and he was uncomfortable, but the voice persist
for some time and disappear on its own.
• Sometimes he feels weak , decreased need for food he
don’t want to eat with out known reason ,collecting
materials which is thrown he said I don’t know it was
dirty, I just pick and take them home but he never
complain when the family throw it out ,also had suicidal
ideation but never act on it .He also has substance use
like “Areke and Tela” ,Areke 5 nip and Tella till 5 glass
per day but no symptom increment or decrement
during intoxication and withdrawal reported.
• The pt has decreased in his daily functioning , Once he
has gone to holy water but no improvement was seen.

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• He has done nothing to cope with his illness
• His symptom has no exactly known thing which can exacerbate his symptom
but as the patient reported symptom worsen when has conflict with his wife
due to his aggressive b/r toward her.
• Currently he is on medication which is red in color which is most likely
chlorpromazine one tab morning and one at night and symptoms like sleep
problem, hearing of voice ,and destructiveness are subsided, but symptoms like
urge to go out ,eating problem are still present.
Otherwise, there is no:
• Suspiciousness
• Attempt of taking one’s own life
• Stressful life event that happened
• Feeling of unhappiness
• Loss of interest
• Excessive ,elated or expansive mood
• Fear of being negatively evaluated
• Fear of speaking in social situations ,
• Fear of specific things like animal, situation , place /environment ,blood and
others
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• Excessive worry
 Past psychiatric illness
• The patient has no past history of psychiatric
illness
• He has history of substance abuse (areke and
tella) use in the past.
• He has no history of suicidal attempt/no hx of
homicide

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 History of medical/surgical history
• He has no known history of any serious
medical illness like DM, HTN, HIV , and no
surgical history
• No known past history of head
injury(TBI),neurological disorder like epilepsy,
headache, and cerebral tumor.

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 Family history
• Both his father and mother are alive. He has 2 brothers and
two sisters, and he is the 3rd son.
• He’s married and has 4 children and lives with them. The total
number of his family members is 6.
• His family have poor income that is not enough to support the
family.
• He is a farmer and was supportive for the family. Due to illness
as he is supportive for family , the family’s living condition is
disturbed.
• His family has good interaction with him and he has good
attitude towards them
• Apart from that, there is no known chronic illness in the family,
no mental illness ,no substance use history, no suicidal history,
and homicidal history
• As his families think the cause for all this is people have casted
a curse on him by a witch doctor because he is a hard worker
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 Personal history
• Prenatal history : the Px was planned and
wanted, there is maternal exposure to substance
like alcohol during pregnancy(px).
• Perinatal history : He was delivered at home and
no known birth complication, trauma was
reported.
• Neonate :patient was breast fed till 2 years
• Middle childhood :grew up with family ,started
school at age of 14 and he was a good student at
that time and he was interested to learn ,has no
history of truancy , cruelty to animals and lying.
• Adolescence :onset of puberty was at age of 17
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 Personal history
• Sexual history : he is married and has only
one sexual partner and no problem in their
sexual life
• Forensic history: no military history , no
history of crime suspected and trouble with a
police
• Premorbid personality: he was kind, very
interactive, and hard working ,has good
premorbid personality
• About his hobby nothing is reported
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 MSE
• General appearance : well dressed hospital pyjama ,
has good eye contact , clean and short nails,
• Motor activity - no psychomotor abnormality is seen
like Mannerism, Tics ,Gestures, Gait ,Stereotyped
behavior , Waxy flexibility and Stupor
• patient is cooperative and interested toward the
interview
• Speech relatively normal rate, volume and non
spontaneity.
• Emotion : Mood: He said “I feel happy” because
many people are talking to me.
Affect : within normal range
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• Thought disturbance
Form :no clang association , tangentially ,
circumstantialities , thought blocking
neologism
Content :no delusion , idea of reference ,
suicidal ideation ,overvalued ideas like
obsession
• Perceptual disturbance : no hallucination ,
depersonalization , derealization and illusion

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 Cognition and sensorium
• Patient is alert and conscious
• Oriented to time , place, and person
for time we ask “what time it is? “
patient replied "its after noon around 9”
For place “where are u now? “
Patient replied “I'm in Addis Ababa at Amanuel
hospital “
For people “who are the people around here ?”
Patient replied “they are people who are here for
treatment”
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• Attentive and concentrated
For concentration we ask serial 3(subtract 3 from 20)
Pt answer 17,14,11,8..
• Memory is intact
-Immediate : we ask the patient repeat “1,3,5,”
immediately after we asked and then he replied
correctly.
-Recent :we ask the patient what he had for breakfast
then he say ‘dabo” and its correct
-Remote :when did you stop learning? He say “at age
of 11” and its correct

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• Abstract thinking
Difference of lemon and orange was asked
-He said “they have color difference and main thing is
lemon is bitter than orange.” So patient has good
abstract thinking relatively.
• Judgment : good both social and test
Test :what will you do if you saw a child holding gun as
toy?
He said “I’ ll take it from him and ask where he got it and
tell him that its dangerous
• General knowledge : has good general knowledge:
“who was pm of Ethiopia before Abiy ?”
Answer: “H/Mariam D.”
• Insight : partial insight

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 Physical examination
• Temperature = 36.8 degree Celsius
• RR=24 b/m
• PR=86 b/m
• Head- no scar and mass
• Ear-no discharge, or wound around the ear
• Eye- pink conjunctiva
• Nose-has no nasal discharge
• Mouth-dry mouth
• Neck -no thyroid enlargement ,able to move his neck
properly.
• MSS=no deformity on both extremities
• Skin =no rash and scar
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 Discussion Questions
1. List /summarize sign and symptoms based on Patient’s history
and MSE……Group 1
2. Identify etiology /risk factors for the patients disorders based on
history & MSE…..Group 2
3. List differential diagnosis(ddx) and put the correct DSM -5
diagnosis as per history (hx) and MSE …… Group 3
4 . What is the pharmacological and psychological treatment for z
patient? …..Group 4
5. Identify predictors of good/bad outcome and prognostic factors
based pt’s problem…. Group 5

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