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. Seizure disorder

ii. 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