LUSAKA APEX MEDICAL UNIVERSITY

FUCULTY OF MEDICINE

END OF YEAR EXAMINATION

Psychiatry 410

2020

Time allowed 3 hours

CASE STUDIES
This question paper has 10 case studies, you are to attempt all case
studies, each carrying 20 marks only.

You are encouraged to spend at least 18 minutes per case study and
you are to analyze each case study independent of the other.

Remember to write legibly and concisely.

Good luck

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Case Study I

Martin Mukelebai is a 21 year-old accountant student at UNILUS a large university.

Over the past one month his family and friends have noticed increasingly bizarre
behaviors. On many occasions they’ve overheard him whispering in an agitated voice,
even though there is no one nearby. Lately, he has refused to answer or make calls on
his cell phone, claiming that if he does it will activate a deadly chip that was implanted in
his brain by evil aliens.

His parents have tried to get him to go with them to a psychiatrist for an evaluation, but
he refuses. He has accused them on several occasions of conspiring with the aliens to
have him killed so they can remove his brain and put it inside one of their own. He has
stopped attended classes altogether. He is now so far behind in his coursework that he
will fail if something doesn’t change very soon.

Although Martin Mukelebai occasionally has a few beers with his friends, he has never
been known to abuse alcohol or use drugs. He does, however, have an estranged aunt
who has been in and out of psychiatric hospitals over the years due to erratic and
bizarre behavior.

Interaction

i. Lift two differentia diagnosis for Martin. 2 marks

ii. Which one of the two is the definitive diagnosis, state your reasons. 4 marks

iii. How do you wish to help Martin? 14 marks

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Case Study II

He entered your consultation room without Knocking and started introducing himself as
Emmanuel Chisanga; as you looked up, you couldn’t help but notice that he looked well
kempt and well nourished, he had pointed brown shoes with well pressed purple
trousers and a navy blue neck tie on a white shirt.

He continued to talk before you could say anything.

He said he had been on medication for the past five (5) years, three (3) drugs which
had run out now as he took his last dose in the morning.

You offer him a seat and he gladly takes it while he continued to talk.

You decide to interrupt him to ask him which drugs he had been taking if he knew them,
he tells you he couldn’t remember but one of them was said to have been reducing his
shakes. He suddenly stood up and picked his pockets, took out his phone and put it on
your desk.

You asked him what he does for a living and he answered that he was a Minister of
God. He ministers to everyone; he continued that he was closer to God than everyone.
He continued with his conversation stating why he stopped work and how well he has
been looked after by everyone.

Interaction.

i. What do you think is wrong with Emmanuel, state your reasons. 3 marks
ii. How do you want to help Emmanuel? 17 marks

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Case Study III

Agnes Banda is a 28 year-old married female. Agnes has always been a high achiever
in the University. She graduated with top honors in both college and LAMU Faculty of
Medicine. One particular thing that is unique about Agnes is that she has very high
standards for herself and can be very self-critical when she fails to meet them. She likes
all the things surrounding her to be orderly, she says there is no room for disorderliness.
She often gets agitated when she misses a laid down plan. Lately, she has struggled
with significant feelings of worthlessness and shame due to her inability to perform as
well as she always has in the past.

For the past few weeks Agnes Banda has felt unusually fatigued and found it
increasingly difficult to concentrate on the wards. Her fellow post graduate students
have noticed that she is often irritable and withdrawn, which is quite different from her
typically upbeat and friendly disposition. She has called in sick on several occasions,
which is completely unlike her. On those days she stays in bed all day, watching TV or
sleeping.

Agnes Banda’s husband has noticed changes as well. She has shown little interest in
sex and has had difficulties falling asleep at night. Her insomnia has been keeping him
awake as she tosses and turns for an hour or two after they go to bed. He has
overheard her having frequent tearful phone conversations with her closest friend Sofia
Mudenda, when he tried to get her to open up about what’s bothering her, she pushes
him away with an abrupt saying that “everything is fine”.

Although she hasn’t ever considered suicide, Agnes Banda has found herself
increasingly dissatisfied with her life. She has been having frequent thoughts of wishing
she was dead. She gets frustrated with herself because she feels like she has every
reason to be happy, yet can’t seem to shake the sense of doom and gloom that has
been clouding each day as of late.

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Interaction.

I). List three differential diagnoses identifiable in Agnes. 3 marks

II).Defend each of your differential diagnoses above. 3 marks

III).Bipolar I and Bipolar II diagnostic entries were not part of the Differential Diagnoses
for Agnes above, if you were to consider such, in which entry would you place Agnes,
Bipolar I or II. What is the reason for your choice? 2 marks

IV) How do you want to help Agnes? 12 marks

Case Study IV

Joel Kasonka was a 55-year-old retired Clinical Officer who was living with his son and
daughter-in-law. His wife had died some 10 years previously. Over the past few years,
Joel Kasonka had become increasingly forgetful, something his family passed off as
‘just growing old’. However, the forgetfulness kept getting worse, until one day he lost
his way around his own home. He started forgetting the names of his relatives, including
his favorite grandchildren.

His behavior became unpredictable; on some days, he would be irritable and easily lose
his temper, while on others he would sit for hours without saying a thing. Joel Kasonka’s
physical health began to deteriorate and one day he had a fit. Joel Kasonka’s son
brought him to hospital, whereas special scan of the brain was done; this showed
changes in the structure of the brain which confirmed that Joel Kasonka had dementia.

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Interaction

i. Apart from dementia what other problems does Joe have? 2 marks

ii. What would you do for Joe? 18 marks

Case study V

Mary Kamukwamba, female estimated 30 years presented to your clinic one day looking
worried but could say what she was worried about.

On direct inquiry, she tells you that she was pregnant and concerned about the baby.
You want to ask more questions but she is not willing and looked down, not talking
anymore.

Suddenly she begins to cry and saying it was better if she had died, not to live like this.

You beg her for an examination and hesitantly gets on the examination bed.

You notice that she had no recollection where she stays and what date that was. You
notice scratch marks around the neck and that she was of bad odour, her hair initially
wrapped in head dress was exposed and had mud and twigs in it.

She trembled a little as you see spots of healed abscesses on her gluteal regions and
upper limbs, some wounds were fresh with central areas that looked like tiny insect bite
sites. These sites where linear, more like following contours of veins.

The abdomen showed a height of fundus of 28 cm and there ware palpable moving
foetal parts intrauterine.

Interaction

i. Highlight on relevant history that you might want known and helpful towards your
management. 3 marks
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 ii. What are the problems you have identified in Mary? 3 marks
iii. You decide to order investigation, restrict yourself to 3 key investigations since
you are in a resource constrained area to give you a window into management.
3 Marks
iv. Why have you ordered the investigations above? 3 marks
v. What would you want to do for Mary before the child is born? 3 marks
vi. Indeed you have done a good job, Mary safely delivers a baby boy of weight
1.9kg at term. This baby was smacking his lips and boxing occasionally and was
failing to breast feed. How do you want to manage this child? 3 Marks

vii. How do you want to care for Mary and the Child going forward in life?
5 marks

Case study IV

Loveness Mbangweta is 55, a Primary School Teacher and mother of seven, suffered
from an illness. Her family believed that her illness was due to evil spirits and took her to
various shrines in Kalabo, but she showed no signs of improvement. She felt like
leaving her home and running away and attempted suicide several times. One of
Loveness Mbangweta’s colleagues told her about a mental health outreach facility run
by the Primary Health Care Team in Kalabo. There, psychiatric personnel diagnosed a
severe illness.

Loveness Mbangweta started attending counseling sessions and taking medication. In

six months, her condition started to improve. After three years of medication and regular
follow up from the Primary Health Care Team, the doctor advised that she could stop
her medication. Since 2016, Loveness Mbangweta has been working at the Women’s
Group Development project, launched by PHC Team, in Kalabo where she trains and
assists women recovering from mental illness and their caregivers to learn a trade and
develop small businesses.
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Interaction.

i. If you were loveness’ family, how would loveness present for us to suspect evil
spirits/ Demon possession in our relative? 2 marks
ii. Following your responses above, what are the differential diagnoses?
2 marks
iii. What made the family of loveness to take such action of taking their relative to
shrines than a conventional hospital? Speculate. 3 marks
iv. Following your Differential Diagnoses above, be kind to manage loveness.
13 marks

CASE STUDY VII

Johanis Milimo is a 27 year-old male living in Avondale Lusaka who recently moved
back in with his parents after his fiancée was killed by a drunk driver 3 months ago. His
fiancée, a beautiful young woman he had been dating for the past 4 years, was walking
across a busy road intersection in Cairo Road of Lusaka to meet him for lunch one day.
He still vividly remembers the horrific scene as the drunk driver ran the red light, hitting
down his fiancée right before his eyes.

He raced to her side, embracing her crumpled, bloody body as she died in his arms in
the middle of the crosswalk. No matter how hard he tries to forget, he frequently finds
himself reliving the entire incident as if it was happening all over.

Since the accident, Milimo has been plagued with nightmares about the accident almost
every night. He had to quit his job because his office was located in the building right
next to the little café where he was meeting his fiancée for lunch the day she died. The
few times he attempted to return to work were unbearable for him. He has since
avoided that entire area of the Lusaka Town.

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Normally an outgoing, fun-loving gentleman, Milimo has become increasingly
withdrawn, “jumpy”, and irritable since his fiancé’s death. He has stopped working out,
playing his guitar, or playing basketball with his friends – all activities he once really
enjoyed. His parents worry about how detached and emotionally flat he has become.

Interaction

i. What are the two differential diagnoses? 2 marks

ii. Explain your differential diagnoses. 2 marks
iii. You consider Milimo for Psychotherapy and you settle on Cognitive Behavioral
Therapy. By way of one sentence per choice, which specific areas of this
management would you focus on? 7 marks
iv. How do you further want to help Milimo? 7 marks

Case Study VIII

‘Oh my husband is dead’. You hear a woman’s voice as this panicky family alights from
the ambulance.
You had dispatched you hospital ambulance following a call from the community that
there was a man about to die and the well-wishers were quick to give the address.
You rush to meet the family, all crowding the stretcher as your staff wheel the patient
into acute bay.
The woman while sobbing narrates to you as you arrive, ‘you see I always tell him this
beer one day will kill you. He just left home around 1600hrs yesterday that he would be
at the tavern, which he usually does almost on a daily basis. But then he came home
staggering, we offered him food he couldn’t take it and it’s still on the table this morning,
oh my husband, how could you leave me, who will keep me.’
You decide to do the ABC and indeed airway was clear, he was breathing, and had a
heartbeat of 110 beats per minute, the BP was 160/100mmHg, with a respiratory rate of

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100 per minute, he was lacrimation. He felt hot, the thermometer reading was 38. 5
degrees Celsius.
Indeed you ask politely from the relatives if you could be allowed space to help him and
they comply quickly and rush outside.
Interaction
i. What immediate things are you considering doing? 6 marks
ii. The wife runs back to you and gives a small sachet open of some substance
found in his pocket. She shouts, ‘he seems to have taken these’. What
substance would this be and why, before you subject it to laboratory tests?
2 marks
iii. You emergency management as above has worked well, he become conscious
after 2 hours. You decide to talk to him, what would you ask him?
3 marks
iv. How do you wish to proceed with your management of him? 9 marks

Case Study IX

Peter Kabuswe was discovered by a Primary Health Care Team in 2018. The 29 year
old Primary School Teacher had developed the symptoms of mental illness after his
marriage failed and he began smoking cannabis. His behaviour changed – he became
aggressive, disappeared from home for days on end and didn’t wash.

He even started killing his own domestic animals, believing it was a ritual to protect
himself, and left home to live in the market square of Mpika as he felt his family disliked
him. Eventually the community in the Township forcibly took him to a traditional healer
some 20 km from Mpika Town as his family couldn’t afford treatment.

The traditional healer drilled a hole with a huge log and forced Peter Kabuswe’s leg
through it, imprisoning him. He was kept like this for nearly a year and a half. After the
Primary Health Care Team discovered traditional healer at the traditional healer’s home
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some 20 km, from the town Centre they referred him to Mpika General Hospital where
there is Psychiatric Clinical Officer. With medication and support from a loyal friend and
his second wife, Kabuswe has returned to teaching and is looking to rebuild his life.

Interaction
i. What is the definitive diagnosis? 1 marks
ii. Why do you think that is the diagnosis? 1 marks
iii. What were the causative factors for this illness 2 marks
iv. Why did the traditional healer behave in the manner he did? 2 marks
v. If the Psychiatric Clinical officer referred Kabuswe into your care what would you
have done different for Kabuswe? 14 marks

Case study X
Japhet Monde male 7 years presented to your clinic with complaints of chronic cough.
Apparently he was brought in by his parents who said he had been coughing for some
time, “on and off”.
All this while he was in his father’s arms and did not look concerned with your activities.
You asked the parents to put Japhet down and indeed they comply. They put him down
on the sofa in your office.
You notice that he had to be supported to sit and did not care to communicate with you.
You try to communicate with him. ”Hello Japhet.” He continued to roll his eyes and then
the parents intercept. “Oh Japhet was born like this, we care for him this way, he does
not talk. If he communicates he does this with his eyes, see now he is looking at you
and now you say something to him.” Indeed you say, “Hello.” Then he fixes his eyes on
you. “The Doctor where we came from said he had Cerebral Palsy, but we have been
transferred to here and the doctor wrote us a not to give to you”.

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Interaction.

i) What appropriate diagnoses would you want to work with on Japhet, away from
the Cerebral Palsy that he came with? 2 marks
ii) Why do you give diagnoses above? 2 marks
iii) How do you wish to manage Japhet on that day? 4 marks
iv) What day today problems do you anticipate on Japhet 4 marks
v) In psychotherapy what would be your focus on Japhet? 4 marks
vi) Following you primary diagnosis on Japhet, would you consider Psychotherapy
for this condition, clearly without beating about, explain your answer.
4 marks

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