DEPT.

OF PSYCHIATRY

Mrs.Murugeshwari 28/female Xth std. Married since 7yrs., housewife Informant- mother R/A/C Ist psychiatric consultation and admission

Irrelevant talk Over familiarity Abusive and assaultive behaviour Sleep disturbance

past 1 month

Acute onset

Continuous
Progressive Not precipitated by stressor

Goes to nearby houses during day and night Talking for hrs. together Answers not pertaining to the question Pacing around home at night Doesnt take care of child Increased anger outbursts towards child Assaultive behaviour towards family members Laughing to self

No h/o blurring of vision, headache, vomiting No h/o Frequent micturition No h/o Intolerance to heat, excessive appetite, palpitation H/o constipation, but no cold intolerance, hoarse voice No h/o Fever, head injury,seizure

Diagnosed as Sheehans syndrome 1 yrs back Found unresponsive at home, admitted in unconscious state Found to have hypoglycaemia, hypotension Corrected with ionotropics and iv fluids

INVESTIGATION T3

NORMAL VALUE 20-70 mcg/dl

PATIENTSVALUE 17.3 mcg/dl

T4 TSH
FSH LH CORTISOL

5.5-13.5 mcg/dl 0.2-4.5 mIU/ml

3-10 mIU/ml 5-18 mIU/ml 5-23 mcg/dl

2 mcg/dl 4.17 mIU/ml

0.5 mIU/ml 0.79 mIU/ml 1mcg/dl

Gynaec opinion sec. amenorrhoea Radiology opinion empty sella

Pt. was diagnosed as Sheehans syndrome and supplemented with

Tab.Wysolone 40 mg 1 HS Tab.Eltroxin 100mcg 1 OD

past 1 years
Tab. Premarin .625mg for 21 days

Tab.Meprate 10mg 16th -25th day

As on 02/05/12 - general condition improved - no psychotic symptoms

Psychiatric illness in paternal aunt

muttering ,suspiciousness Delusion of persecution, marital infidelity Onset at 35yrs, continuous illness Committed suicide at 50 yrs

Psychiatric illness in paternal cousin

Onset 25 yrs Muttering to self Laughing to self Withdrawn wandering behaviour Diagnosed as schizophrenia,on teatment

ANC uneventful Natal FTND, GH PN - uneventful

Childhood- uneventful
Scholastic below average, discontinued Xth

Menstrual A/M 14yrs, regular 4/30. 2 yrs of amenorrhea . LMP - 6 months back with OCP substitution

Married since 7 yrs, third degree consanguineous

One abortion in first trimester

ANC- uneventful Natal FTND, GH, wt.- 3kg, no H/o prolonged labour

Severe wt. Loss, Fatigability Failure to feed Slowness in day to day activity Amenorrhea

Decreased sexual drive

Emotionally stable

Self sufficient
Trusting Warm Enthusiastic

Extrovert type

Pt. conscious , oriented No pallor/icterus/clubbing/cyanosis/ gen. lymphadenopathy Vitals PR-74/min, BP- 100/70 CVS- S1 S2 (+), No murmur RS NVBS, No added sounds Abdomen- soft, no organomegaly Loss of axillary & pubic hair No thyromegaly

Conscious, Oriented Rt. Handed individual

RIGHT UL/LL LEFT UL/LL NORMAL NORMAL 5/5 NORMAL NORMAL NORMAL 5/5 NORMAL BILATERAL FLEXOR

BULK TONE POWER REFLEXES PLANTAR

Sensory system normal Cranial nerves - normal No cerebellar signs No gait abnormality Spine & cranium normal

Pt. alert, ambulant In touch with surroundings Brought by attender for interview Sat in the seat offered Looks appropriate for age Dressed adequately Not groomed well Gets up frequently from the chair in between the interview Frequently self absorbed smile noted during interview

Rapport established with difficulty Gaze contact made but not maintained Psychomotor activity increased No abnormal movements No mannerism

TALK spontaneous excessive talk relevant Shifts to irrelevancy Prosody not maintained

THOUGHT Flight of ideas

PERCEPTION

MOOD

no abnormality

inappropriate

Bizarre delusion

Increased self esteem

Quantumincreased tone rate- normal

RT- normal

Attention, concentration

Orientation

Memory

General fund of knowledge

Abstract thinking

Judgment to test situation

Time Arousable

Place

Recent impaired

Adequate

impaired

impaired

Not sustained

Person

Insight Absent

Tests applied Rorschach Ink blot test less no. of popular responses, contamination, more anatomical responses TAT thought disturbances noted Suggestive of psychosis - NOS

YMRS scores 17 BPRS scores 17

PANSS
POSITIVE SCALE -14 NEGATIVE SCALE 13 GEN.PSYCHOPATOLOGY SCALE 32

MMSC scores 13 NEUROPSYCHOLOGICAL ASSESMENT

Impairment in executive functions

Tests of memory
Immediate verbal and visual memory intact
WORKING MEMORY - impaired Mild impairment In verbal learning & memory

Hb -10.2 gm/dl Urea -28 mg/dl Sugar -82mg/dl Creat 1.2 mg/dl Na+ - 140 meq/l K+ - 4.2meq/l cl- -107meq/l Hco3- -28meq/l Urine alb-nil Urine sugar nil Deposits 0-3 pc/ Hpf ECG- WNL USG ABDOMEN AND PELVIS Normal study

Lipid profile

sr. cholestrol 154.68 mg/dl Sr.triglycerides 464.55 mg/dl HDL - 19.26 mg/dl LDL 42.51 mg/dl VLDL 92.91 mg/dl

TFT- normal

T3- 1.33 ng/ml T4 8.28 g/dl TSH 0.873 IU/ml

FSH- 3.30 mIU/ml LH 2.01 mIU/ml Prolactin- 0.091 ng/ml (normal: 4-23 ng/ml) ACTH- 10 pg/ml

NORMAL MRI

PATIENTS MRI

Anterior pituitary appears thinned out with partial empty sella height 4mm (normal-10mm) Posterior pituitary- bright spot could be visualised No significant pathology/ focal lesion in brain parenchyma

Murugeshwari 28/f ,married with c/o irrelevant talk, over familiarity, abusive behaviour, sleep disturbances past 1 month, past h/o Sheehans synd. On steroids and HRT family h/o Schz. Illness,.

Personal h/o amenorrhea, failure of lactation, decreased sexual drive, Loss of wt., fatigability, after delivery, GE loss of axillary & pubic hair, MSE decreased attention, concentration, impaired recent memory, impaired judgment & abstract thinking, absent insight.

Provisional diagnosis-Psychosis not otherwise specified Treatment given tapered steroids Added T. Risperidone 2 mg b.d after 4 weeks

Psychomotor activity normal Talk relevant No psychotic features at present No abusive /assaultive behaviour Symptoms improved

 Steroid

induced psychosis

Year : 2011 | Volume : 15 | Issue : 7 | Page : 203-207 Sheehan's syndrome: Newer advances C Shivaprasad Department of Endocrinology, M. S. Ramaiah Hospital, Bangalore, India Date of Web Publication13-Sep-2011

Sheehans syndrome is characterized by varying degrees of pituitary dysfunction due to postpartum ischemic necrosis of the pituitary gland after massive bleeding.

The main involvement is decreased secretion of growth hormone (GH) and prolactin (90-100%), while deficiencies in cortisol secretion, gonadotropin and thyroid stimulating hormone (TSH) ranged from 50 to 100%. At least 75% of pituitary must be destroyed before clinical manifestations become evident.

HORMONES T3

NORMAL VALUES 20-70 mcg/dl

SHEEHANS SYNDROME decreased

T4
TSH S.CORTISOL FSH LH

5.5-13.5 mcg/dl
.2-4.5 micro IU/ml 5-23 mcg/dl 3-10 micro IU/ml 5-18 micro IU/ml

decreased
Normal or decreased decreased decreased decreased

The goal of therapy is to replace deficient hormones. The treatment is essential hormone replacement: thyroxine 50mcg per day, hydrocortisone 40mg per day.

Gonadotropin deficiency and hypogonadism should be treated with a hormone replacement therapy.

For patients with diabetes insipidus, treatment of choice is 1-desamino-8-d-arginine vasopressin or desmopressin (DDAVP).
GH should be started on a low-dose regimen (0.10.3 mg/day

Mania and hypomania in 35% of patients Acute psychotic disorder in 24% of patients Depression, which is more common with chronic corticosteroid therapy, in 28% of patients Delirium and cognitive deficits also have been reported

1.3% of patients taking <40 mg/d 4.6% of patients taking 40 to 80 mg/d 18.4% of patients taking >80 mg/d.

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