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help regarding a "psych patient"

Hello doctors! I'm trying to help my friend who is currently rotating in Psychiatry, handling this case below. Based from my limited knowledge, I don't see any Psych illness from this history. What I can see is a possible case of DM. Do you agree???

Mr. X, 42 year old, male, enlisted serviceman admitted at a Psych ward"

2 days PTA, during an all-day physical & mental training while snake gliding, he noticed that he was having a hard time moving forward. He suddenly felt lightheaded but without any headache. Nevertheless, he still went on with the course, but when he was about to get up and run, he felt as if he was floating. His fellow soldiers noticed that he was wobbling as he walked so they brought him to a clinic. There was no vomiting, loss of consciousness, mood changes or hallucination. Patient claims he had enough sleep the previous night, eaten his breakfast, drank up enough water just before the training and was not taking any medication.

1 day PTA, the patient was requested to accompany a military officer outside the camp on a long trip to the city. Without his knowledge, he was brought to a Psychiatric ward of the military & was admitted w/ a dx of Behavioral Changes 2 to General Medical Condition.

PmHx: S/P Craniotomy 1985 due to head trauma. Px recovered.
Medications: none
ROS: unremarkable
PE: unremarkable

Labs & radiography: all unremarkable except
Glucose: 6.73 mmol/L (NV: 3.90-5.80)
Eosinophils: 0.10 (NV: 0.02-0.04)
ECG: Nonspecific ST-T wave changes

I haven't seen the px but for me, but with this hx, I don't think he should be admitted in psych ward. What do you think? What illness can you think of, if any?


  • AltweggAltwegg PEx Influencer ⭐⭐⭐
    What was the chief complaint?
  • According to the patient, "Nahihilo ako. Parang umiikot paligid ko.

  • AltweggAltwegg PEx Influencer ⭐⭐⭐

    I'm also wondering why he was admitted at the Psychiatry ward. Maybe the history-taker missed out some important details in the HPI. Anyway, given this history and laboratory, I would say his symptoms may be attributed to diabetes.
  • poor old man, does the history taker asked about the client concerns before the history taker recommned the old man to be admitted to a psych ward,my heart goes for the old man,seriously..

    well according to your stats that you presented i think that the old man is just experiencing a some sort of a dissociative fugue,or i miss my guess,i only have limited knowledge about psychiatry but i guess i have to take a look on my DSM-IV.
  • err.. obviously the given data doesn't permit us to make a psychiatric diagnosis. anamnesis? MSE?

    all day training with those kinds of symptoms should point to hypoglycemia, not hyperglycemia. and the random glucose isn't even that high to cause a change in mental status. no data with meals taken prior to blood extraction. a random blood sugar of 6.73 really doesn't say much.

    with the limited information, i would say hypoglycemia primarily, with heat exhaustion, substance abuse, malingering, syncope ranking high up in the differentials.
  • thanks everyone. i appreciate all your input. i know, the HPI doesn't say much about the his psych illness. Initially i thought this is another case of a malingering soldier. many soldiers do that to avoid work. i asked my friend to suggest to the doctor to have the FBS repeated.
    The px has been taking Epival since his admission. According to the px, he has no seizures.

    here's the anamnesis

    Prenatal & Perinatal History: He claims his pregnancy was planned. The patient was born full term via normal vaginal delivery by a midwife in their residence. There was no known complication.

    Early Childhood: He was breastfed for about two years. He was toilet trained when he was around 3-4 years old.

    Middle Childhood: Enuresis ceased when he was in 3rd grade. He described himself as friendly, but he prefers to be alone most of the time. He grew up with his grandparents. They took care of him and sent him to school. He helped in the household chores and was given responsibility of taking care of the family pets. He described his grandparents as meticulous, affectionate and amicable. They were not disciplinarians, but emphasized to be honest and respectful to everyone.

    He was not a rowdy nor was he bullied by anyone. He prefers to stay at home to study or tend his garden. He was not really into sports but plays at times. He describes this phase of his life as the time he explored and played at the same time.

    Late Childhood: He started to have crushes with the opposite sex when he was in high school. However, he had a hard time approaching them. ***** started at this stage. Knowledge about sex was obtained friends and classmates. He claims he was too shy to ask his parents about it. He feels that sex is good but should remain private and not be hashed out especially when there are women around, out of respect to them.

    He claims he was more studious than being athletic. He had few friends and would usually go home to take care of his plants and pets. He never tried smoking nor drinking, since he claims he could stand the smell and taste of it. He was doing well academically but at this time, earning money and at the same time gaining experience from work is a priority. Hence, he started working as a sugar mill porter at an early age of 14 without being forced by anyone. He packs sacks of sugar right after school till 4 AM the following morning Despite these, he was able to finish high school, while working odd jobs.

    Occupational History. The patient claims that it was his childhood ambition to be a serviceman. Hence, right after high school he joined the army.

    Marital & Relationship History. The patient wooed her first girlfriend for four months. They tied the knot in 1988 in Iligan City, Lanao del Norte. Regrettably, their relationship became unpleasant two years after their wedding when she started gambling. To finance her stakes, she either sold or mortgaged their properties, including the house he built for the family. Sales of their retail store funds her gambling. Moreover, he claims he never felt the love and attention a husband is supposed to enjoy. She never cooked for nor asked him about how his day was. His wife together with their children abandoned him in 2003. He decided not to look for them. Since then, he never heard from his family again. In 2005, he met his mistress who is also estranged from her own family. He describes her as a complete opposite of his wife. An ideal wife: thoughtful, heedful and easy to converse with. Presently, they are cohabiting. She visits him frequently and takes care of all his needs. He plans to stay on the relationship they started after his hospital discharge.

    Military History. The patient was 17 when he entered the military for training. Currently, he has been serving for 25 years. He claims that he is happy with his work and never had conflicts with colleagues.

    Education History. He studied in xxx Elementary School and finished high school in Iloilo.

    Religion. The whole family considers themselves as Roman Catholics. However, they seldom go to church.

    Social Activity. The patient prefers to stay at home when not working and tend to his garden. He likes plants; in fact, he could have become a good farmer if he was not in the military. He is not into sports or drinking. He seldom goes out with his colleagues except during special occasions. His mistress visits him from time to time. Last time she visited was two weeks ago. Oftentimes, they communicate via text messages.

    Current Living Situation. His salary goes directly to his mistress.

    Legal History. He claims he was never arrested nor was placed in probation. No history of assault or violence.

    Sexual History. He first masturbated when he was 12. His first coitus was when he was already enlisted.

    Fantasies & Dreams. He wanted to start a new family with his mistress and live a peaceful life.

    Values. Thinks that children are not burden to him. They are his source of joy and wanted them to grow as good citizens. Believes that work is a normal part of every man’s life. He has been working hard to provide the needs of his family. He thinks suicide is wrong.

    here's the MSE upon admission: Feb 2007
    The patient is clad in blue hospital uniform, fairly kempt and groomed. Cooperative with good eye contact. Euthymic mood with appropriate affect. Speech is normoproductive, without hesitancy noted although he is evasive to questions regarding his wife and his children. The patient had flight of ideas. He had no hallucination or morbid ideation. Memory is intact. Judgment and impulse is good. Insight is poor. Wala akong sakit. Hindi dapat ako dito sa psychiatric ward.
  • If the admitting physician attributes the personality or behavioral changes to the pre-existing DM (DSM 310.1?) then I think the admitting diagnosis is justifiable and also the subsequent admission to the psychiatric ward. The fact that the patient has poor insight towards his illness (mental or otherwise) should be addressed (as well other issues such as depression etc).
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