Transcript A girl with multiple Neurological Symptoms

Clinical Meeting On
A girl with multiple
Neurological Symptoms
Chairman:
Dr. Bhidhan Ranjan Roy Podder
Assistant Professor and Head of the Dept. of Psychiatry
Mymensingh Medical College
Speaker:
Dr. S.M. Ali Imam
Assistant Registrar of the Dept. of Psychiatry
Mymensingh Medical College
Particulars of the patient:
Name: Farhana
Age: 14 years
Sex: Female
Address: Dhanikhola, Trishal, Mymensingh
Marrital Status: Unmarried
Religion: Islam
Occupation: Student of class VIII
Name of the informant: Hazera Khatun (Mother)
Date of examination: 14.02.12
Chief Complaints with duration:
i.
Headache and convulsion for 3 years
ii.
Intolerance to bright light with double vision for 1month
iii.
Difficulty in walking for 5 days
iv.
Weakness of right upper and lower limbs for 5 days
History of Present illness:
According to the statement of the patient’s attendant, she
was apparently well 3 years back. Then she developed
headache. The headache was episodic, relates with nausea,
occur unilaterally or bilaterally. She also complains of
intolerance to bright light and double vision in presence of
bright light even in absence of headache for 1 month.
After 6 months of initiation of headache she developed
convulsion. The convulsion occurs for prolong periods
(30- 60 minutes). No history of tongue bite,
incontinence, loss of consciousness during convulsion.
This type of convulsion occurs several times in a year
specially when she thinks about her familial stressful
condition.
For last 3 months her headache and intensity of
convulsion increased. She also develops difficulty in
walking and weakness in her right side of body for 5
days, after admission in hospital. She was admitted in
medicine unit –I, therefore she was transferred to
psychiatry ward on 06.02.12.
Past Psychiatric History:
Not reported.
Past Medical Illness:
She complaints of swelling of her large joints and sore throat 5
years back, which was diagnosed as rheumatic fever and
treated accordingly. She improved and stopped taking drug
for 1 month without consultation.
Drug History:
She was treated with tab. Pizotifen for 1 month for headache
and with tab. Sodium valproate for one a half year for
convulsion with no response.
Family History:
There is no clear family history of psychiatric illness. But her
sister, aunt and uncle had history of headache.
History of Stress:
She has a long history of mental stress. Her father married
second time during her childhood and most of the time he
stays with his second wife. Whenever he comes home, he
quarrels with his 1st wife. She worries about her familial
disharmony but can’t express her feelings.
Personal History:
Birth history: Normal delivery
Milestones of development: Normal
Schooling: Normal
Occupation: Student of class VIII
Habit: No bad habit
Immunization: Completed as per schedule
Premorbid Personality
Relationship with others: She is introverted, has few friends
Leisure activity: Reading books
Predominant mood: Depressed
Copping capability: Low
General Physical Examination:
Body built: Average
Anemia: Absent
Jaundice: Absent
Cyanosis: Absent
Clubbing: Absent
Pulse: 80 beats/ min
Blood Pressure: 110/70 mmHg
Heart: NAD
Lungs: Clear
Spleen: Not palpable
Liver: Not palpable
Kidney: Not palpable and ballotable
Thyroid gland : Not palpable
Lymphnode: No lymphadnopathy
Nervous System Examination:
Higher psychic function: Described in MSE
Speech: Normal
Cranial nerves: Intact
Motor examination:
Muscle bulk- Normal
Muscle tone- Normal
Muscle power- Some weakness in right side.
Reflex- Normal
Gait- Scissor like
Hoover’s test: Positive
Sensory examination:
Touch- Diminished on the right side
Pain- Diminished on the right side
Temperature- Normal on both sides
Romberg’s test- Negative
Signs of meningeal irritation: Absent
Signs of cerebeller dysfunction: Absent
Ophthalmic Examination:
Refractory error- Cylindrical (-0.5) on both eye
Vision- Normal
Fundus- Normal
Mental State Examination:
General Appearance: A young girl lying on bed with
appropriate dressing according to culture.
Facial Appearance: Looks apathetic
Eye to eye contact: Reduced
Behavior: No abnormal behavior seen
Speech: Reduced
Mood: Reports normal but affect depressed. No loss of
interest , no hopelessness or suicidal ideation.
Delusion: Absent
Hallucination: Absent
Cognitive function:
Orientation- Intact
Memory- Intact
Attention, Concentration- Intact
Intelligence- Normal
Judgment- Intact
Insight- Intact
Salient Feature:
Farhana, 14 years year old student, hailing from
a middle income family of rural background
presented with headache, convulsion for 3
years, photophobia and diplopia for 1 month,
gait disturbance and weakness of right upper
and lower limbs for 5 days.
Salient feature:
She has no family history of psychiatric illness
but has positive family history of headache. She
was treated for rheumatic fever for 5 years. For
headache and convulsion she was treated with
antimigrain
drug
and
anticonvulsant
respectively.
She has a strong history of familial disharmony
since her childhood.
Her premorbid personality was introverted with
low mood and low stress coping capacity.
On physical examination no specific abnormality
was detected. The minimal positive
findings
does not correlates with known neurological
patterns.
Mental state examination shows, depressed mood
with no other psychiatric symptom.
Provisional Diagnosis:
Conversion Disorder with Migraine
Differential Diagnosis:
i.
ii.
Seizure disorder
Intracranial space occupying lesion
Investigation:
(Done on 04.02.12)
TC- 8600 /cmm
DC- N-53.6%, L-38.5%, M-4.9%,E-5.6%, B-0.1%
Hb-12.5 gm/dl
ESR- 10 mm in the 1st hour
ASO titer- 400 IU
RBS- 4.4 mmol/L
S. creatinine- 0.9 mg/dl
Investigations:
S.electrolyte: (Done on 04.02.12)
Na- 141.3 mmol/l
K-3.98 mmol/l
Cl-108.6 mmol/l
MRI of the brain- Normal (Done on 11.10.10)
EEG- Normal (Done on 12. 2.12)
TSH- 6.48 mIU/L (Ref: 0.3-5 mIU/L) Done on 16.02.12
Confirmatory Diagnosis:
Conversion disorder with Migraine with
hypothyroidism
Treatment:
DRUG: Antidepressant
Thyroxine
Psychological: Psychotherapy