siblings with autism, intellectual impairment, & ADHD

 31 may 2022

both males one aged 6 years & 9 months & the other, 7 years & 9 months.

father said mother drank alcohol when pregnant. they were on and off & now separated. father with another wife.

the younger has MILD while the older has MODERATE intellectual developmental disorder

NB: this should serve as a warning to pregnant mothers 

>"Alcohol in the mother’s blood passes to the baby through the umbilical cord. Alcohol use during pregnancy can cause miscarriage, stillbirth, and a range of lifelong physical, behavioral, and intellectual disabilities. These disabilities are known as fetal alcohol spectrum disorders (FASDs)." https://www.cdc.gov/ncbddd/fasd/alcohol-use.htm

>"There is no known safe amount of alcohol use during pregnancy or while trying to get pregnant. There is also no safe time for alcohol use during pregnancy. All types of alcohol are equally harmful, including all wines and beer."

>"Alcohol use in the first three months of pregnancy can cause the baby to have abnormal facial features. Growth and central nervous system problems (e.g., low birthweight, behavioral problems) can occur from alcohol use anytime during pregnancy. The baby’s brain is developing throughout pregnancy and can be affected by exposure to alcohol at any time."

blooshot eyes & marijuana (cannabis)

an  ER px was referred to us today when I was the only left in the MHSC bldg. the uncle said it's due to drugs. the father said he was just studying modules at home & he ended up "catanonic" & "mute" (he's normally quiet according to them).

what caught my attention, aside from an unusually clingy behavior was the bold red blood around his eyes. our lady guard also thought it was due to illegal drug use.

& so, I googled: 

ttps://americanaddictioncenters.org/health-complications-addiction/signs-drug-use-eyes

"... Bloodshot eyes are a common symptom of INTOXICATION from several drugs, especially alcohol, cocaine, & MARIJUANA: these occur because blood vessels in the eyes EXPAND.

"... PINPOINT PUPILS are a symptom of OPIOID intoxication & overdoes."

>MARIJUANA: Bloodshot eyes are one of the most common side effects of marijuana intoxication.

https://cannabis.net/blog/smoke/why-getting-stoned-gives-you-red-eyes-and-how-to-deal-with-it

"...Consuming THC (TetraHydroCannabidiol) lowers BP, which then results in DILATION of the capillaries & blood vessels. When the ocular capillaries dilate, BLOOD FLOW to the eyes are increased & intraocular pressure is then reduced. 

The increased blood flow results in red eyes while the PRESSURE DECREASE benefit patients who are suffering from GLAUCOMA.

> strains with LOW THC content --> MILD red eyes

> strains with HIGH THC content --> BLOODSHOT eyes

prolonged grief disorder: case # 01

19 may 2022

35F teacher who on 2020 may 30 lost her newborn child. tearful when alone & the memory comes back, like posttraumatic stress. 

during psychotherapy, I asked her to dialogue with her baby through the empty chair technique & she did so tearfully, leading to some degree of closure. 

Nonsuicidal Self-Injury Disorder case # 01

ICD-10 Code R45.8 Other Signs & Symptoms involving Emotional States

again, for the 2nd day, got a "first". 

"nonsuicidal self-injury disorder" is now a "condition under further study" in DSM-5-TR (2022).

11 May 2022

walk-in. 36M. chief complaint: insomnia & self-injury marks on arms. 

HPI (history of present illness): ~ 9 years PTC (prior to consult) wife left for Iloilo together with their 2 kids aged 7 & 5 (bringing them there for the 1st time) & never returned. mother of SU (service user) told him she heard she already married. SU used to work in a candy factory in caloocan, then a messenger in a bank in CSJDM but lost his job due to alleged in-fighting among colleagues.

1 mo PTC SU started to cut his arm with pictures like television & fish in the evening. his daily routine includes going to the river to take a bath around lunch time & then spends the whole day watching tv or the mobile phone.

psychotherapy yielded insignificant gains due to emotional (& physical) numbness. he just went through the motions & needed to be prodded. techniques intended to elicit emotional release were largely ineffective. referred to psychiatry.

 

on permanency of autism

 10 may 2022 

i assessed this 2-year-old female service user (SU) in 2019 due to delayed speech (age 3-4 years old started to talk) without a standardized intelligence test but with a vineland social maturity scale & the childhood autism scale & SDM-5 screening tool with the diagnostic impressions of F84.0 autism spectrum disorder (ASD) with intellectual & language impairments, T/C F70 mild intellectual developmental disorder & F90.2 ADHD, combined presentation.

today, 2 years & 9 months after, at age 5 years & 8 months, we assessed her again with the help of our practicum students. i had wanted the stanford-binet to be given, but since it's not easy, I did not insist. instead, I asked that the raven's (abstract reasoning) be given since it has norms starting at age 5.3 & she got an estimated IQ of 112 (high average) & with an estimated mental age of 6 years & 4 months. 

I was in a dilemma as to whether to still give the diagnostic impression of  ASD since the full range of required symptoms are no longer present. to the credit of the parents (the SU is an ONLY CHILD!) , they completed the 12-session package with our visiting SPED interventionist & elsewhere. so, the DEVELOPMENTAL PROGRESS was phenomenal (this is the principle of EARLY INTERVENTION), plus the fact that her level of dysfunctionality is not severe (most probably mild only -- I validated this by asking the parents for comparison with diagnosed cousins with ASD as well).

since, I could not let the parents wait for additional hours (needing time to research further), i ended up limiting my diagnostic impression to T/C (To Consider) F80.0 speech sound disorder because that was the outstanding area needing remediation in the social maturity scale.

then,  I read this from DSM-5-TR (2022) on ASD, p.62 (in reference to criterion C. "symptoms must be present in the early developmental period...." which reads "Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests, or activities were CLEARLY PRESENT during childhood or at some time in the past, EVEN IF SYMPTOMS ARE NO LONGER PRESENT." (this is a verbatim repetition of DSM-5, 2013, p. 54).

moreover, DSM-5-TR adds this interesting admission of limitation: "However, the symptoms of ASD occur as DIMENSION WITHOUT UNIVERSALLY ACCEPTED CUTOFF SCORES for what would constitute a disorder. Thus, the diagnosis remains a CLINICAL one, taking all available information into account, & is NOT SOLELY dictated by the score on a particular questionnaire or observation measure" (p. 62).

panic disorder triggered by multiple marital, financial, & family-of-origin problems

10 may 2022

36F

female orgasmic disorder F52.31

06 may 2022

this is my first case of such kind. 30F with PDD (persistent depressive disorder F34.1) & panic d/o (F41.0) with history of rape in childhood & adolescence by visiting cousins from the province whenever there are no people at home.

family medicine rotator learning content

Re: DJNRHS Family Medicine Psychiatry RESIDENT Rotation LEARNING CONTENT

 

A.   PRIMARY CASES = The FamMed Res shall carry out all phases of Dx & Tx WITHOUT consultation in 90% of cases. The Tx will consist of SUPPORTIVE THERAPY.

1.    Stress Reaction

a.    Grief (mourning)

b.    Death, separation, etc. (with depressive & anxiety features)

2.    SITUATIONAL REACTIONS

3.    Psychosomatic Illnesses – MILD Syndrome

a.    Peptic ulcer

b.    Colitis, anorexia

c.    Asthma (with minimal psychological dysfunction)

d.    Rheumatoid arthritis

e.    Hypertension

f.     Dermatoses

g.    Migraine

 

B.    SECONDARY CASES = the FamMed Res shall maintain PRIMARY responsibility to the case but usually needs consultation at one point. Therapy mainly SUPPORTIVE with some INSIGHT-DIRECTED therapy.

1.    SITUATIONAL REACTION

2.    Psychosomatic Illnesses – SEVERE Syndrome (with greater dysfunction of the px)

3.    TRANSIENT Situational Disturbance

a.    Adjustment Reaction of Adolescence

b.    Adjustment Reaction of Late Life

4.    Chronic Psychotic, per discretion of Psychiatry Res Coord (by mutual agreement of PRC & FMR)

 

C.   TERTIARY CASES = the FamMed Res shall recognize those cases but does NOT maintain primary responsibility & refers px for both Dx & Tx.

1.    Psychoses not attributed to physical conditions

a.    Schizophrenia

b.    Affective Disorders (Affective psychosis) – involutional, manic-depressive

c.    Paranoid States

d.    Other Psychoses

2.    Neuroses

a.    Anxiety Neurosis

b.    Hysterical Neurosis

c.    Obsessive-Compulsive Neurosis

d.    Depressive Neurosis

e.    Hypochondriasis

f.     Depersonalization Neurosis

3.    Borderline syndrome

4.    Personality disorders

a.    Paranoid

b.    Cyclothymic

c.    Schizoid

d.    Explosive

e.    Obsessive-compulsive

f.     Hysterical

g.    Passive-aggressive

h.    Inadequate personality

5.    Sexual Deviation

a.    Homosexuality

b.    Fetishism

c.    Pedophilism

d.    Transvestism

e.    Exhibitionism

f.     Voyeurism

g.    Masochism

6.    Alcoholism – Drug Dependence

7.    The Psychosomatic Illnesses (psychological factors play a critical role in the illness) – duodenal ulcer, lleo-colitis, bronchial dysfunction, genital dysfunction, organic neurosis, etc.

8.    Behaviour Disorders of Childhood and Adolescence

9.    Speech Symptoms: Speech Disturbance, Disorders of Sleep, Enuresis, Coprolalia, etc.