Wednesday, July 18, 2007

Help me to diagnose (case 2)

Chief complaint: disturbed memory for 1 month…
Since 1 month and the patient is having difficulties in performing learned skills like cooking food and washing dishes and clothes and taking care of her children….yet the patient got no difficulty at all in remembering names of persons, objects, nor having any difficulty in language.
When she is given cues about how to do a previously learned skill she remembers the skill easily and start to do it with ease.
Her husband noticed that she had difficulty in taking decisions, and always responds to his suggestions by "I don't know", or by "as you like", even to simple daily decisions.
Before 3 years, after moving from Beigit to Mosul and a change in economic status due to loss of her job as a teacher due to the political change after the war of 2003 in Iraq, she started to have strange sensation in her head (tingling), and difficulty in getting asleep for 20 days followed by going out of her house suddenly one morning and making a long trip to unknown cause to multiple places and going back late in the evening to home.
She continued to have difficulty in sleep and abused benzodiazepines, but she start later to have some repetitive non goal directed movements, poor appetite, decrease speech, self neglect, and lastly hearing voices giving commands.
She first visited a psychiatrist in 2005, and was treated by a combination of drugs. But after few months she also left the house suddenly, but this times she phoned her husband telling him that she was kidnapped by a gang, she was found to be calling from a public phone and that she was lying, that was explained by her that she wanted to kill herself, without leaving a trace…
After having a still birth in late 2005 she wrote a letter and left in the house stating that she was kidnapped by a gang and no need to search for her…
She was found after that in the streets after trying to through herself from a bridge as she claims…
Since the beginning of her condition and she never went back to her previous functioning

Got no family history of mental illness

Mental State Exam.:
Middle aged lady, clean, skin rash in her face, tense, sitting restless on the edge of the chair and wringing her hands, cooperative, obedient, but perplexed.
Scanty speech with low voice.
Got command hallucinations asking her to kill herself…
Cognitive exam reveals poor concentration, attention, and memory.

9 comments:

Jennifer Robinson said...

The lady you talk about has develpoed tolerances to benzos They are making her ill You must get her off them slowly look at benzo.org.uk

3eeraqimedic said...
This comment has been removed by the author.
saminkie said...

Thank you for your comments....i will check for benzodiazepine addiction as a cause...and publish my results of the search...thank you Jennifer Robinson...

Regarding the comment of 3eeraqimedic I was very happy by it, and it remembered me of the mistakes a junior psychiatrist like me usually do...and it is the forgetting of organic causes... I actually saw that lady in last April, but i still got the records...I remember that my senior psychiatrist just say the exact things you have said and that is: what about neurological exam? skin rash? imaging? and ESR and other signs of aotuimmune disease (SLE) ?
I had done all these thereafter...and was all negative...

so 3eeraqimedic, you have a mind of a senior psychiatrist....better than me, am a junior!
thank you again
please keep send comments...

Anonymous said...

Hi Dr. Sami,

All I can think of is that all or most of the sympyoms relate to her sadness from the loss of her baby and perhaps the fact that no one took the time to understand how truly devestated she was/is. Well, that along with everything everyone else has mentioned. (How was that last part for "taking the easy way out...?) So much has happened to her in such a short amount of time...and as others mentioned, some forms of emotional illness came come "out of the blue", seem to have no real cause" are just waiting beneath the surface for some event to trigger them.

All my best wishes always, tracy

Anonymous said...

Hi sami,
I have no words to appreciate your good work. But one thing i can say is i am so impressed by your magnum opus site that your web blog is one of the subject of discussions among my friends in India. I never fail to discuss your blog with people i know.. Keep it up
Your friend Komal from India

Anonymous said...

You may want to consider neuropsych testing. Sometimes acquired brain injuries present themselves as psychiatric. I know of a patient who presented smiliar to yours. After a few years and a lot of frustration the patient tested and significant cognitive problems was recognized. Cognitive rehab was the best resource for this patient.

Anonymous said...

Hello Dr. Sami,

What ever happened to this poor lady? I have been wondering...So much has been written about the benzos, etc, the delusions, perhaps a psycosis, I keep thinking about the very sad events...how so much of her self worth and self esteem may have been tied to her job that was lost...the friends and associations she lost there, and of course, again, having a miscarriage, that must have been a terrible thing to have happen to her and maybe no one really took the time to understand that event. Just a few thoughts, probably "over emotional"...! Please take good care, Dr. Sami and keep up the excellent work and the wonderful blog...you are a very kind and good person. Thank you, tracy

Anonymous said...

I ment a still birth, not a miscarriage, sorry about that. A still birth may have been even more horrible and so sad for her than a miscarriage...tracy

Anonymous said...

One of the rarer dementias? Like Lewy Body kind?

http://www.ajnr.org/cgi/reprint/26/10/2527.pdf

Does she have any other apraxias? (If you tell her to do something, does she do it right? Buccofacial apraxia? Constructional?

Did you find out anything more? This is very interesting.