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Neuropsych Conference

Neuropsych Conference. March 16, 2012 Block 10A. General Data. R. DR 4 4/M Married Right-handed Unemployed From Muntinlupa CC : behavioral changes. Profile. History of trauma, s/p craniotomy (2008) Diagnosed with seizure disorder (2009) Phenobarbital ½ gr. BID, poor compliance

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Neuropsych Conference

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  1. Neuropsych Conference March 16, 2012 Block 10A

  2. General Data R. DR 44/M Married Right-handed Unemployed From Muntinlupa CC: behavioral changes

  3. Profile • History of trauma, s/p craniotomy (2008) • Diagnosed with seizure disorder (2009) • Phenobarbital ½ gr. BID, poor compliance • Last seizure: Jan 23, 2012 • PTB, adequately treated • Alcoholic beverage drinker: 20 years

  4. History of Present Illness • 4 mos. PTA • (+) behavioral changes, insomnia, anorexia • (+) auditory hallucinations • episodes of intoxication  violent behavior wife and children left

  5. History of Present Illness • 4 mos. PTA • Seizure episode • Stiffening of extremities • Upward rolling of eyes • Drooling • Loss of consciousness • Post-ictal confusion • Brought to PGH  managed as a case of seizure disorder

  6. History of Present Illness Interim: • Poor compliance (Pb BID)  recurrence of seizure episodes (last Jan 23, 2012) • Advised to consult at Psych OPD  lost to follow up • Persistence of violent behavior, auditory hallucinations and paranoia  consult  admission

  7. Review of Systems (-) Weight changes (-) Fever (-) Headache (+) BOV (-) Nausea, vomiting (-) Cough/colds (-) Chest pain (-) DOB (-) Abdominal pain (-) Changes in bowel movement (-) Dysuria/hematuria (-) Tremors (-) Palpitation

  8. Past Medical History As stated No DM, HPN, asthma, allergies, kidney/liver disease No other hospitalization/surgery

  9. Family Medical History (+) Hypertension - mother (+) Heart disease – mother (-) Diabetes / stroke / epilepsy / asthma / allergy (-) Psych illness (+) Substance abuse – sibling (+) Kidney disease -sibling

  10. Personal/Social History • Currently unemployed • Used to live with wife and 3 children (ages 9, 8 and 7) • Alcoholic beverage drinker – 20 yrs • (+) smoking – since elementary, consuming 1-2 packs per day

  11. Anamnesis Informant: patient Born full term via SVD to a then 32y/o G7P6 (6006) mother, no fetomaternal complications Childhood: shy but had close friends; average in school

  12. Adulthood: • Finished 2nd year of Criminology due to illicit drug use and alcohol drinking • (+) MAP use, other drugs  sometimes hurts himself • Held several jobs (bartender, waiter, factory worker) • Felt that his coworkers were gossiping about him  (+) violence against a coworker • Once a full time preacher of El Shaddai • Had 2 intimate relationships: married in 2011, has 3 children

  13. 2009 • Vehicular crash (jeepneyvs pedestrian); intoxicated • s/p craniotomy • Post-op: worse alcohol drinking, episodes of forgetfulness

  14. Physical Exam Awake, alert,follows commands, NICRD BP 120/80 PR 88 RR 20 T 36.8

  15. Systemic Examination • Head and Neck • Anictericsclerae, pink conjunctivae, (-) masses/discharge, (-) CLAD, (-) anterior neck mass, (-) dentition • (+) skull depression, right temporal area • Chest • Equal chest expansion, clear breath sounds • Heart • Adynamicprecordium, distinct heart sounds S1 and S2, normal rate regular rhythm, (-) murmurs

  16. Abdomen • Flabby, normoactive bowel sounds, soft, nontender • (+) several hypertrophic linear scars, midline • Skin / Extremities • Full equal pulses, pink nailbeds, (-) cyanosis/clubbing/edema • (+) multiple hyperpigmented scars on ventral side of forearm

  17. Assessment • Axis I: • Psychosis sec. to general medical condition (seizure disorder) • Major depressive disorder • Alcohol dependence, in controlled environment • Axis II: deferred • Axis III: Seizure disorder, s/p craniotomy, evacuation of hematoma (2009) • Axis IV: Poor primary support; economic problems • Axis V: GAF 31-40

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