1. CL Rounds October 14, 2009

2. General Data SL 28/M RH Married unemployed Union Espiritu Kalinga, Apayao Admitted Aug 22, 2009 for the first time in PGH Informant: patient and wife-good reliability

3. Chief complaint: Psychiatric complaint: Depression Orthopedic complaint: B LE weakness

4. History of Present Illness: 1 Yr PTA  Numbness at bilateral feet with mild weakness which progressed with sensory loss  (-)trauma/fever. Patient was ambulatory but claimed to have limping gait. There was bowel and bladder incontinence, No consult at this time and no medical intervention.  started to manifest with depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia.

5. 11 mos PTA: ▫Weakness of both feet ascended to both legs without sensory loss. At this time, the patient had no urine output for 2 days. He then consulted at a local hospital. Folley Catheter was inserted and was sent home. There was no associated fever, hematuria, dysuria. ▫He consulted with a private physician and was given with the Impression SCC. CT Scan was not done due to lack of funds. At this time, the patient was still ambulatory but needed moderate- maximal assist.

6. Aug 2009 ▫consulted at PGH. MRI was done which showed spinal and epidural soft tissue mass, causing spinal cord stenosis and cord compression patient was then advised surgery hence admission ▫depressive symptoms (+) depressed mood feeling of hopelessness and worthlessness, insomnia, anorexia, decreased in intensity after starting treatment in PGH. ▫Patient again started having said symptoms with anhedonia and thoughts of death after he was informed of difficulty securing donors and funds for his operation. ▫Patient is still somehow hoping though that he will be able to walk again, as what his attending physician informed him.

7. Review of Systems: (-) fever (-) headache (+) weight loss (+) anorexia (-)DOB (-)chest pains (+) incontinent bowel and bladder (+)sweats

8. Past Medical History malaria at 10 y/o PTB (2006)- incomplete treatment Hospitalization (2006) secondary to PTB x 10 days (-) DM/HPN/Heart Dse/Allergy/BA/liver and kidney dse

9. Family Medical History (+) Cardiac, pulmonary dse Wife has ANM undiagnosed x 8 yrs (-) DM/HPN/Heart Dse/Allergy/BA/liver and kidney dse (-) same condition

10. Personal Social History Currently a non smoker and non alcoholic beverage drinker, denies illicit drug use Patient is currently unemployed He previously worked as a farmer His regular diet includes mainly vegetable and raw fruits He lives with his wife, 3 children, father and sister-in-law in a 1 story house with wooden flooring in a studio type nipa hut

11. Functional History Premorbidly independent in all ADLs like grooming Min-mod assist in bed mobility and transfers from wheelchair to bed Good sitting balance and tolerance Needs max assist and support from a stable furniture Incontinent bowel and bladder

12. Anamnesis Patient is the eldest among 5 living siblings. He was breastfed and had his proper toilet training at age 3. As a child, he was active and friendly. He plays with the children around the neighbourhood. And he gets along with his siblings well. He was sickly as a child. But this did not prevent him from making friends or caused any withdrawal from playing and making friends.

13. The patient did not go to school and did not have any formal education. As said by his wife, he can’t read or write. At 19, he got married. Present has 3 children being 9, 6 and 4 year old. The eldest is being sent to school. The patient and his wife are both farmers. They have no problem with the simple life that they have until this present condition where it threatens to tear down the simple happy life that they are most contented with.

14. At present, numbness is felt from feet up to waist down. The patient cannot walk and stand without the aid of help. He keeps himself in bed. And occasionally becomes uncooperative. The operation he needs cannot be scheduled without any blood and funds. The patient expresses his wish to go home. Because of the almost 3 months stay in the ward, resources with time are depleting. This mainly includes food for the bantay, pamasahe going back to the province to seek help and also visit the children and family. The patient has no relatives in Manila. So his wife and father stay with him at the wards.

15. Physical Examination General Survey: Conscious coherent, oriented to three spheres and NICRD BP:110/70 HR: 71 RR:20 afebrile HEENT ▫PC, AS, (-) TPC, (+) CLAD, (+) anterior neck mass, soft, nodular, non tender moves with deglutition, (-) bruit CHEST AND LUNGS ▫ECE, CBS, (-)crackles/wheezes CVS ▫AP, DHS, (-)murmurs ABDOMEN Flat, NABS, (-) bruit, nontender

16. Neurologic Examination alert, coherent, oriented, NICRD CN intact Motor ▫normotonic, fair sitting balance and tolerance, B UE active and passively done, B LE passively done ▫UE: 5/5 ▫LE: 3/5

17. Sensory ▫C2-T6: nosensory impairment to pain and light touch ▫T1-S3: impaired sensation to pan and light touch DTRs ▫++ B UE ▫+++ B LE (+) Babinski (+) Sustained clonus (-) Nuchal rigidity

18. Mental Status Exam The patient is alert, oriented to three spheres and cooperative. The patient is cooperative and attentive, dressed appropriately according to age and gender, calm with fair eye contact. He showed no odd behaviours. He was smiling most of the time and speaks spontaneously with normoproductive speech and soft voice. He has a broad affect and euthymic. His thoughts were productive and goal oriented. He has no memory impairment remote, recent, and past.

19. He admits that at the moment, he has thoughts of dying. He has no idea on a specific manner of ending his life, but just the thought and idea of death. He sees death as the only way that would end his sufferings and his family as well. He sees himself as useless and only gives constant problems to his family. He says to himself in his thoughts, if I were dead, maybe I can be of more use because I am not a burden anymore. Intact cognition, fair insight, impulse control and judgement He has no persecutory delusions, hallucinations.

20. Assessment

21. Diagnosis Axis I: Mood disorder secondary to a general medical condition vs MDD Axis II: None Axis III: Spinal cord injury, incomplete ASIA D, level T4, prob secondary to potts disease vs metastasis from a thyroid primary Axis IV: financial constraint, medical illness, inability to work AXIS V: GAF: 61 – 70 (some mild symptoms [depressed mood or mild insomnia] or some difficulty in social, occupational fnc

22. Differential diagnosis – AXIS I Mood disorder secondary to GMC Major depressive disorder Adjustment disorder with depressive symptoms Diagnostic criteria Prominent and persistent disturbance in mood characterized by either or both 1.Depressed mood or diminished pleasure or interest 2.Elevated, expansive, irritable mood Direct physiological consequence of a GMC Not accounted by another mental disorder Not during a delirium Sx cause significant impairment in function

23. Differential diagnosis – AXIS I Mood disorder secondary to GMC Major depressive disorder Adjustment disorder with depressive symptoms Major depressive episode (5 or more) Depressed mood for most of the day Diminished interest or pleasure Significant weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or low energy Feelings of worthlessness inappropriate guilt Decreased concentration, ability to think and indecisiveness Recurrent thoughts of death

24. Differential diagnosis – AXIS I Mood disorder secondary to GMC Major depressive disorder Adjustment disorder with depressive symptoms Not a mixed episode Causes significant distress and impairment in social, occupational and other important functions Not a direct physiological effect of a substance or a general medical condition Symptoms are not because of bereavement

25. Differential diagnosis – AXIS I Mood disorder secondary to GMC Major depressive disorder Adjustment disorder with depressive symptoms Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within the 3 months of the onset of the stressors Symptoms or behaviors are clinically significant as evidenced by ▫marked distress that is in excess of what would be expected from the exposure to the stressor ▫Significant impairment in social or occupational functioning Stress related disturbance does not meet the criteria for another axis I or II disorder Symptoms not because of bereavement Symptoms resolve within 6 months

26. Bereavement May present similar to depression Usually doesn’t involve prolonged feeling of: Worthlessness Guilt Self reproach Thoughts of death

27. Biopsychosocial Formation Biological Factors Psychological Factors (internal in the patient) Social Factors (external/ outside world) Predisposing Factors Pulmonary TB (2006) Poor self-esteem Low educational attainment lack of awareness regarding need for consult Poor health care system in the area Precipitating Factors Spinal Cord Compression Feeling of worthlessnessLack of funds Perpetuating Factors Progressive weakness, sensory deficit (-) resolution of symptoms Continued unproductivity Thoughts of hopelessness of the condition Continued delay in surgery Depletion of resources ( food, fare)

28. Treatment Goals Ensure patient’s safety Address immediate symptoms and prospective problems

29. Treatment Plans

30. ▫Cognitive therapy (expressive – empathic)  Address ego regression (damaged self-esteem and unresolved conflict due to childhood loss or disappointment)  Promote personality change through understanding of past conflicts  Achieve insight to defenses, ego distortions, and superego defects  Provide a role model  Permit cathartic release of aggression Psychosocial Therapy

31. ▫Interpersonal therapy (behavioral – cognitive)  Address distorted thinking (dysphoria due to learned negative views of self, others and the world)  Provide symptomatic relief through alteration of target thoughts  Identify self-destructive cognitions  Modify specific erroneous assumptions  Promote self-control over thinking patterns

32. ▫Behavior therapy (communicative – environmental)  Address impaired interpersonal relationships (absent or unsatisfactory significant social bonds)  Provide symptomatic relief through solution of current interpersonal problems  Reduce stress involving family or work  Improve interpersonal communication skills

33. ▫Family therapy  Examine the role of the mood-disordered member in the overall psychological well-being of the whole family. And the role of the entire family in the maintenance of symptoms.

34. Pharmacotherapy ▫Patient education regarding the possible side effects of medications and the need for compliance and other drug-drug and drug- food interactions ▫Selective Serotonin Reuptake Inhibitors  Effective, easy to use, relative lack of adverse effects  Examples: fluoxetine, paroxetine, sertraline, venlafaxine, bupropion, etc.

35. ▫Tricyclic Antidepressants  Lethal when taken in overdose, cardiotoxic, causes hypotension, decreased libido, erectile dysfunction, anorgasmia  Examples: amitriptyline, desipramine, imipramine, nortriptyline ▫Monoamine Oxidase Inhibitors  Causes serotonin syndrome (hyperthermia, muscle rigidity and altered mental status) when taken with SSRIs, meperidine and pseudoephedrine, also causes hypertensive crisis when ingested with foods rich in tyramine  Examples: phelzine, tranycypromne

36. Electroconvulsive therapy: used when the patient is unresponsive to pharmacotherapy or cannot tolerate pharmacotherapy or clinical situation is to severe that the rapid improvement seed with ECT is needed Phototherapy for those with seasonal mood disorder

37. Treatment Duration When in full remission, maintain treatment for at least 4-6 months in case of first-time episode but longer in recurrent disease

38. Thank You!

39. Biological Factors Psychological Factors (internal in the patient) Social Factors (external/ outside world) Predisposing Factors Pulmonary TB (2006) Poor self-esteemPoor health system in the area Precipitating Factors Spinal Cord Compression Feeling of worthlessness Lack of funds Perpetuating Factors Unable to have an operation UnproductivityDepletion of resources ( food, fare)