NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA

(CASE SUMMARY)

# Candidate’s information
1 Surname: ADELAJA Other names: ADENIKE SILIFAT
2 Training institution: ABUTH ZARIA
3 Rotation institution (if different from the training institution): Click here to enter text.
4 Supervising consultant for the rotation: DR. AUDU. I.A.
Period of rotation: 6 MONTHS
5 From m/d/y: 9 To m/d/y:
6 Posting: GENERAL PSYCHIATRY

Patient information
7 Initial: A. Z

8 Date admitted m/d/y: 9 Date discharged m/d/y: 9

Details: 400-500 words (Remember to anonymized the Sociodemographic and other relevant data)
9 29-year married woman admitted with undue sadness of 5 months duration, reduced
energy of 3 months and suicidal plans of 1-week durations
There is associated history of inability to initiate and maintains sleep, with early
morning awakenings, has poor concentration, poor appetite and recurrent thoughts of
death and she finds it difficult to do her routine house chores and go for her business.
There is no past history of similar illness
No known family history of similar illness.
No history of medical disorder. She does not use psychoactive substances.
Mental state examination: A young woman, kempt, with poor eye contact.
Also depressed mood, suicidal ideations

Diagnosis: Severe depressive episode

Plan: Admit
Do FBC, URINALYSIS, EUCR, LFT
Tabs amitriptyline 75mg nocte
Tab Vit B complex ii daily
Monitor for risk to self

10 Attestation: ☒I attest that this report is a correct representation of my clinical

encounters with the patient in reference.
11 ☒I attest that my supervising consultant previewed this write-up
before upload.

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 NATIONAL POST GRADUATE MEDICAL COLLEGE OF NIGERIA
(CASE SUMMARY)

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