BUTABIKA NATIONAL MENTAL

REFERRAL HOSPITAL
MAKERERE UNIVERSITY, KAMPALA
COLLEGE OF HEALTH SCIENCES
DEPARTMENT OF PSYCHIATRYi

Student: KIYUMBA Registration number:

RICHARD 17/U/433

Course: MBChB IV. Student numbe: 217000931

Tutor: Dr. NAMULI

Ward: KIREKA WARD (MALS ACUTE ) Date: 25th-MAY-2021

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 PATIENT ‘S DEMOGRAPHICS

Name: CHEMARE PETER

Age: 28
Sex: Male
Address: Seeta Mukono
Tribe: sabin
Occupation: business man selling passion fruits
Religion: Born again Christian
Informant: patient
Marital status: single
Education level: P.6
Referral source: home
Next of kin: Ogwom keneth (father)

PRESENTING COMPLAINT:

Aggressiveness and high energy ×1/52

Talkative ness ×1/52
Difficulty in sleeping for 4 /7
Violent behaviour ×2/7

HISTORY OF THE PRESENTING COMPLAINT:

He was well until one week ago when the people at home started complaining that he was too
talkative and he also blaming people at home for leaving in a dirty environment ,He also started
feeling a lot of energy to do work .
4 days prior to admission, He could hardly sleep because he kept thinking about how to publish
his music as he believes to be the best artist on earth though the world does not appreciate him
but still believe that he is a very important person in this world, He could also do housework
like mopping the house whenever he fails to sleep and even watch T.V.
He also reports being in love with a girlfriend who he met in Butabika a student nurse , only
waiting for the girl to upgrade and they marry.
2 days prior to admission, He reports increase in temper and violent behaviour as he fought with
his brothers and quarreled with his father blaming hin for staying in a dirty environment.
The patient denies any history of suicidal thoughts, change in appetite, feeling of excessive guilt
or restlessness. There is also no history of hearing voices, someone putting thoughts in his head,
someone removing thoughts, people hearing his thoughts or being repeated, denies having felt any
of his body parts missing, people being after him, being talked about on radio or having an
external person controlling his thoughts .There is no history of fever prior to the illness or any
history of substance or alcohol use prior to admission as he reports to have stopped taking alcohol
and cigarettes Smoking in 2017 because alcohol used to make him speak uncoordinated words
and he lso knows that cigarettes Smoking causes lung cancer. He reports no panics ,feeling
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anxious or experiencing fears.
He reports to have stopped going to his bussiness 3days prior to admission as even ghe customers
had started complaining to him something that annoyed him

PAST PSYCHIATRIC HISTORY:

First episode of his illness was in 2014 and he reports being taken to Butabika where he was
admitted for and managed for 1 month where he was given haloperidol, chlorpromazine and
some other tablets he couldn’t recall. He reports similar Symptoms during the first episode, he
returned to his work a and everything was ok.
This is his 9th admission and the most recent being in 2020 where he was managed for the same
Symptoms and he had returned to work and doing it as usual, He was put on carbamazepine but
of recent it has been changed to chlorpromazine.
PAST MEDICO-SURGICAL HISTORY:
He has no history of epilepsy or drug use and stopped taking alcohol and cigarettes in 2017 and
no other chronic medical conditions such as thyroid disease and he is not on any chronic
medications except the medications for the mental illness.
He is HIV negative(results not seen) having last checked in October 2019 but his syphilis status is
unknown. He has no history of major trauma or major operations involving the head
FAMILY HISTORY:
He is the 3rd born on the maternal side out of five children who are all alive. He gives no account
on paternal side but reports that father has many wives and many children but he knows at least
9 . He reports their 2nd born developing similar Symptoms and she was successfully managed at
Butabika and she has never had any remission since 2016 also the last born has mental illnesses
which he couldn't specify but also under management. Both parents are alive Reports a family
history of mental illness on the paternal side and that’s his uncle but no history of other familial
illness like diabetes mellitus, hypertension or alcoholism .He reports that his siblings and the
parents are all supportive.

PERSONAL AND SOCIAL HISTORY:

Birth history
He reports that he was born at term but couldn’t ascertain the other history
Childhood
He reports that he grew up a happy child, with the other siblings in the same home. No history of
child abuse however at age 3 he was pushed by a peer while playing to fall from 3rd floor and
ended up breaking his leg , Hd reports that they also tell him thag he was stubborn during
childhood.
Education history
He reports he was an average student but he got tired of school at the age of 16 when he was in
P.6 because he wasn't understanding anything in class and decided to try his luck elsewhere
especially in business .
Occupation history
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He sells passion fruits and mangoes and hd gets enough income to sustain his life.
SOCIAL DEVELOPMENTAL
He likes music so much , his hobbies were preaching the Gospel and watching football however
he reports no habit though he reports that his reaction when you annoy him is always beating you
up.
SEXUALITY AND RELATIONSHIPS
He reports having slept with atleast 15 women but he stopped after realizing that women just
waste your time and they can also make you sin
He reports to be in love with nurse who he met while being managed in Butabika and the nurse
was a student, he says they talk on phone and planning to marry after shd has upgraded
SOCIAL HISTORY
He still stays at his father's home and lives with his family
He spends his leisure time in preaching the Gospel, playing ludo and watching T.V

FORENSIC HISTORY:
He reports no encounter with police or the legal department at any time in his life however he
reportsthat hd always takes himself to police stations and If they try to detain him, he beats them
all .
PREMORBID PERSONALITY
He reports that people knew him as someone hardworking and sociable people

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MENTAL STATE EXAMINATION:

General Appearance and Behavior:

He is a young man in late twenties. He was dressed in clean short but no shirt , He looked to be
in good hygiene, hair of normal distribution and was well nourished, his appearance looked
appropriate for his age and came in walking with a lame gait and looked relaxed.
Assumed a normal posture on sitting with normal psychomotor activity, no tremors or
exaggerated body movements. He was cooperative through out the interview and maintained
good eye contact all through the interview. Had good attitude and attention towards the
interview.
Speech:

He is fluent in Luganda, had pressured speech. The speech is of high tone and volume. Its of
normal rhythm and was so talkative. And could articulate words very well.
Mood and Affect:

Subjectively he said he was happy.

Mood was euthymic and the affect was elevated, full, labile and was congruent with the mood
and appropriate to thought content, He rated his mood as 9 with 10 being the most happiness
ever experienced and 0 the saddest ever.
He has no suicidal ideations, I scored him using the SAD PERSONS score and he got 2
(mild) hence low risk for suicide

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Thoughts:

Form:Thoughts were elaborative with normal rate of flow, coherent and logical.
Thoughts were goal directed as he could answer questions in a linear organized fashion.
Had no flight of ideas , no word salads ,no echolaria , no thought blocking , no neologisms no
circumstantial or tangential speech and no loosening of associations.
Content: He has grandiose type delusions of being the best artist, no persecutory type delusions,
has erotomanic type delusions that he is in love with a student nurse, no jealous type delusions, no
somatic type delusions and no delusions of unspecified type.
Had no ideas of reference, no magical thinking
Has no over valued ideas and nothing preoccupied his mind but he's obsessed with the Gospel.
Alienations: No thought insertions, no thought withdrawal, no thought broadcasting, no thought
echoing. His thoughts do not belong to anyone else.

Perceptions:

He has no auditory hallucinations, has no visual hallucinations, no tactile hallucinations, no

olfactory hallucinations, no gustatory hallucinations and no somatic hallucinations. he has no
illusions.
He has no derealisation and no depersonalisation.

Cognition:

Orientation: He knows where he is and the reason why he is here .

He refers to me by my true name and he calls me doctor. He knows the time from the day,
month and the year.
Level of consciousness he was alert.

Memory: After telling him three words: pen, ball and food, he is able to repeat them immediately
and at 5 minute intervals for four times. He attaches right days of the week to the dates.
Therefore he has a good immediate, short and long term memories with a good intellect.
Attention and concentration: When he subtracts 3 from 20, he gets the right answer and he can
count the months of the year backword.

General knowledge: He knows that Museveni is current president of Uganda and that 9th-
October-2020 was a celebration for Uganda’s Independence.

Numeracy: He knows that if every cow has 4 legs, 5 cows would have 20 legs.

Judgment and Abstraction: If he had seen a baby seated in the road and a car coming toward
the baby, he would be as fast as possible to pick the baby so that the car does not knock it
therefore good judgement .
Insight: Has full insight of his sickness as he's aware about his sickness and believes he needs to
take medication for him to be stable.

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 SUMMARY:

Chemere peter , a 28 year old male.he is seronegative for HIV and was brought in by his
relatives on Saturday 22nd /5/2021 due to history of becoming aggressive and increased energy
for 1/52, talkativeness for 1/52 , sleep disturbances for 4/7 and violent behaviour for 2/7
. This is his 9th admission in Butabika for similar Symptoms since 2014 the most recent
episode being in 2020.
He reports history of mental illness that affected his two sisters and paternal uncle. reports
having stopped taking alcohol and cigarettes Smoking in 2017 however no history of taking
alcohol, smoking tobacco or using any other substance or trauma or epileptic attack prior to
these episodes.
He has grandiose delusions and erotomanic delusions but no any form of hallucinations.
He is calm but talkative and with pressured speech, no flight of thoughts or expansive mood, no
depersonalization or derealisation, He has a good registration ,short and long term memory and
has good attention and concentration ability, otherwise well oriented in place and person and
time. He has good general knowledge, numeracy, judgment and abstraction and insight.

PHYSICAL EXAMINATION:

Peter is a young man who looks well nourished. He is afebrile to touch. Has no jaundice, no
pallor of skin or mucous membranes, no cyanosis, no finger clubbing, no oedema, no
lymphadenopathy, and no dehydration
Has a temperature of 36.8°c , a pulse rate of 86bpm and respiratory rate of 14 breath per
minute.
DIAGNOSIS:
Axis I Diagnosis:

 Principle diagnosis:

Bipolar Affective Disorder, but currently in partial remission (In view of: previous manic
episodes like over talking ,decreased need for sleep, irritable mood, grandiose delusions, flight
of ideas in the past )

 Differential diagnosis:
1. Schizoaffective disorder (In view of disorganized behavior and mood symptoms)
2. Delusional disorder(in view of grandiose delusions)

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Axis II Diagnosis: narcissistic personality disorder (in view of grandiose sense of self
importance,fantasies of unlimited sucess)

Axis III Diagnosis:

.
o I would wish to rule out Syphilis and Thyroid disease.

Axis IV Diagnosis:

o Predisposing factors:
 Genetics. (Family history of mental illness in first degree relatives )
o Precipitating factor
 non adherence to medication
o Perpetuating factors:
 single marital status
o Protective factors:
 currently has no disabling illness.
 Supportive family members

Axis V Diagnosis:

He has mild symptoms (pressured speech,over talking) but generally functioning pretty
well with meaningful interpersonal relationships Code 70-61 of the Global Assessment of
Functioning (GAF) Scale.

INVESTIGATIONS:

Investigations Immediate Short term Long term

Biological -HIV test. -repeat test - Urea and Electrolytes;
-Syphilis test (TPHA) especially Complete Blood Count;
-CT scan (to rule out brain RFTs,LFTs Thyroid function i.e.
pathologies TSH,T3 ,T4 and ECG;
-LFTs,RFTs OGTT CBC

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Psychological Young Mania’s Rating Scale. Young Mania’s Young Mania’s Rating
rating Scale Scale
Social Collateral history from next of Collateral history Follow up reports from
Kin from other Family members
family members and neighbors at
and neighbours home.
at home

MANAGEMENT:

Peter is being managed as an in patient because he was brought in with aggression and violent
behaviour and had stopped adhering to the medication

Management Immediate Short term Long term

Biological -control an acute -Aimed at hastening recovery -aimed at preventing
episode from acute episodes recurrences and
-give antipsychotic and -give antipsychotic plus residual affective
benzodiazepine anticholinergics to combat symptoms so bashir is
-his insomnia was extrapyramidal side effects always expected to
treated with come for follow up
clonazepam but now visits
changed to
carbamazepine 400mg
bd

Psychological -Need to stabilize - Cognitive-behavioural -Follow up of the

patient first with acute Therapy (CBT) for control of Patient to ensure
episode the temper/ anger management. sustainability of the
-Interpersonal psychotherapy. behavior.
-Family therapy -Interpersonal
psychotherapy.
-Family therapy
Social -Educating the patient -Educating family members -Discharging the
about his illness. about the patient’s illness. Patient.
-Emphasizing the role -Seeking family support for the -Following up the
of drugs to the patient. patient in management of the patient, to monitor
condition e.g. reminding the his progress.
patient to take medications.

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PROGNOSIS:

The prognosis in my patient is good because he has a good insight about his illness, family
support and a moderately a fair business to provide an income for his wellbeing , however he
has had 9 episodes in just 7 years and all necessiting admissions

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CASE DISCUSSION:

Chemere peter , a 28 year old male had Bipolar Affective Disorder. There are several criteria
sets for Bipolar Affective Disorder i.e. Single Manic Episode, Most Recent Episode hypomanic ,
Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent Episode Depressed, and
Most Recent Episode Unspecified. Our patient had most recent manic episode

Epidemiology:

Our patient’s condition started at around 20 years of age which is close to 21 years ,the
[3]
mean age of onset for Bipolar Affective Disorder . The lifetime prevalence of Bipolar
Affective Disorder is 1% across the world. It is equally common in men and women.

Diagnosis:

The condition was diagnosed basing on the patient’s symptoms below which fulfilled the Criteria
required by the DSM-V-TR:

A. Peter’s most recent episode was a Manic Episode i.e. he had the following symptoms
which fulfilled the Criteria required by the DSM-V-TR for a manic episode.
A. He had atleast 1 week period of abnormally and persistently elevated, expansive and
irritable mood that necessitated hospitalization.
B. During the period, he had the following symptoms that had been present to a significant
degree:
1. Inflated self-esteem and grandiosity.
2. Pressure to keep talking.
3. Increase in goal oriented activities
4. Increased psychomotor agitation.
5. Excessive involvement in giving away items despite the losses associated.
6. Decreased need for sleep
Though there was no distractibility and there was no history of thought racing or flight
of ideas . Only three of the above were required.
C. Currently the symptoms did not meet the Criteria for a Mixed Episode.
D. The mood disturbance was sufficiently severe to necessitate hospitalization to prevent
harm to other people.
E. The symptoms were not due to the direct physiological effect of a substance (e.g. a drug
of abuse, a medication or other treatment.) or a general medical condition (e.g.
hyperthyroidism)
Note: His symptoms were not caused by somatic antidepressant treatment.

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 C. The mood episodes in Criteria A and B were not better accounted for by Schizoaffective
disorder and were not superimposed on Schizophrenia, Schizophreniform disorder,
delusional disorder, or Psychotic disorder not otherwise specified.

Aetiology:

Several factors contributed to the condition that Peter has.

Genetics: The patient was genetically predisposed due to a positive family history of mental
illness.

Biochemical: Brain monoamines, e.g. serotonin seem to be increased in mania.

Psychological: precipitating, perpetuating and protective factors were identified for him.

Clinical features:

Bashir had the following clinical features for a manic patient:

Characteristic Clinical feature

Mood Grandiose, Self-confidence, Elevated and expansive
Speech Fast, Pressurised
Thoughts Flight of ideas, with grandiose type delusions
Cognition i had failure to concentrate which is the most obvious cognitive
abnormality in Bipolar Affective Disorder (but he had no disturbance of
registration of memories which is also common.)

Physical Peter had insomnia

Behaviour Great deal of energy which is difficult to contain, Over generous, Sense of
being right and knowing best.

Investigations:

Investigations are biological, psychological and social and are done with the following purposes:

 Ascertain the diagnosis.

 Rule out other possible causes of the presentation (differential diagnosis) e.g. HIV,
Syphilis, Brain pathology (using CT scan)
 Determine severity of the illness e.g. using the Young Mania’s Rating Scale
 Work up for and to monitoring Lithium if it is to be used for management.
 Assess progress in treatment e.g. using Young Mania’s Rating Scale.
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Management:

Patient should be managed biologically, psychologically and socially. The

biological management includes:

 Stop any antidepressant being taken (our patient was not taking any antidepressant)
 Antipsycotics (If typical or high dose atypical, give Artane to avoid
Extrapyramidal symptoms)
 Mood stabilisers i.e. Sodium Valproate, Lithium or Carbamazepine.

Prognosis:

The average duration of a Manic Episode is 2 months, with 95% making a full recovery in time.
Recurrence is the rule in Bipolar disorders, with up to 90% relapsing in 10 years.

REFFERENCES:

1. Linford Rees, Maurice Lipsedge, Chris Ball, 1997, TEXTBOOK OF PSYCHIATRY,

Page 81-97.
2. American Psychiatric association, 2000, DESK REFFERENCE TO THE DIAGNOSTIC
CRITERIA FROM DSM-IV-TR, Page 169,170,182.
3. Parveen Kumar, Michael Clark, 2009, KUMAR & CLARK’S CLINICAL MEDICINE,
th
7 Edition, Page 1204-1206
4. DSM-v
5. Oxford pocket hand book for psychiatry.

End.

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