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:

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 ( 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

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 1 st 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 ) TC /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 1 st hour ASO titer- 400 IU RBS- 4.4 mmol/L S. creatinine- 0.9 mg/dl

Investigations: S.electrolyte: (Done on ) Na mmol/l K-3.98 mmol/l Cl mmol/l MRI of the brain- Normal (Done on ) EEG- Normal (Done on ) TSH mIU/L (Ref: mIU/L) Done on

Confirmatory Diagnosis: Conversion disorder with Migraine with hypothyroidism

Treatment: DRUG: Antidepressant Thyroxine Psychological: Psychotherapy