Prepared by: Dr. Daniel Garang Aluk Dinyo @ St.

Paul’s
Hospital Millennium Medical College, Addis Ababa- Ethiopia
Submitted to: Dr. Solomon (MD, Psychiatrist)
Date: 26th/Feb/2016
A. HISTORY

I. IDENTIFICATION
Patient Initials: TD
Sex: Female
Age: 45 years old
Educational status: grade 12
Marital status: single
Address: Addis Ababa, Inkulal Fabrica
Religion: Orthodox Christian
Ethnicity: Amhara
Occupation: unemployed
Historian: Patient herself and the daughter of her sister through translation
This is the third episode of the patient condition

II. CHIEF COMPLAINT: Sleep disturbance of 8 months duration

III. HISTORY OF PRESENT ILLNESS:

This is a 45 years old female patient who was relatively healthy 8
months back at which time she started to experience disturbance in sleep.
The patient claimed that her current sleeping problem started 8 months
during her bereavement for her brother who passed away, the death of her
brother was sudden and accidental as the deceased fell into toilet and
sustained injury to his neck which lead to his death immediately. One week
later the patient started to experience difficulty in her sleeping pattern. She
said that she was very sorry and regretful for the loss of her brother
considering the fact that her brother died single and he couldn’t married to
have family of his own. After her brother passed away the patient claimed
that she started to have difficulty maintaining the sleep but, she has no
problem initiating the sleep, she also goes to bed at 4:00 local time but
always wake up about 4 our later (at 8:00) and she always has difficulty
going back to sleep until dawn. On the other hand and as compared to her
sleeping pattern prior to current problem, she reported that she used to
sleep from 4 o’clock local time until 11:00 o’clock, unless she had to
wake up in between to urinate. Though patient claims that she couldn’t__
perceived this condition to be a serious problem at first, there is nothing
she could do to solve her sleeping problem and there is no anything that
seems to exacerbate her condition either. When asked why she didn’t seek
any medication attention back then, she claimed that her condition was not
that serious and she was attributing it to be her bereavement for her brother.
Two months back her mother passed away as well and the patient claimed
that her condition got worsen to the extent that she can only sleep less than
4 hours per night once again the problem is not with the initiation of sleep
rather she cannot maintain the sleep. Beside sleep disturbance, the patient
claims that she loss interest in most of the things she used to enjoy such as
watching TV, she also reported that she find it difficult lately concentrating
on any task, she also complained of difficulty remembering things, and that
she most of the time forget where she placed the keys. She reported that
she sometimes has thoughts of death but never attempted to commit suicide
neither does she have a plan to nor does she wish to do so but she reported
that she always feel hopeless and sad since here current problem started.
The patient always burst into tears whenever she feels sad.
Her clothes started to get loosen and she also claimed to have lost
unquantified amount of weight, she had experienced decrement in her
appetite about month ago to the extent that she may only eat once a day.
As her sleep disturbance got worsened the patient couldn’t bear it for more
than couple of weeks and she came 3 weeks back to Saint Hospital
accompanied by her sister’s daughter where she was directed to psychiatric
department, upon arrival the patient was seen by psychiatrist and she was
given diazepam and told to come back after three weeks, but she claimed
that her condition did not improved and that she still has sleeping problem.
Otherwise:
 No history of hearing voice or command that are not heard by other
 No history of seeing things or people that are invisible to others
 No history of unexplained or sudden happiness
 No history of talking alone, laughing alone or any other
disorganized behavior
 No history of head injury or headaches
 No familial history of suicide or suicidal attempt.
IV. PAST ILLNESSES:
Past psychiatric illness: In 1973 E.C the patient claimed that she had
experienced the same sleeping problem but reported that it was a
depression that she had after she failed grade 12 exam. She could recall
that she was very sad and agitated at the same time which urged her family
to promptly take her to the Holy water as a sort of remedy but she showed
now improvement and her family eventually sought a medical attention
and she was thereafter taken to and admitted at Amanuel Hospital for about
a month during which she was receiving unspecified medication. She
improved with the treatment she was getting at Amanuel and she was
discharged a month later, and had follow up for sometimes (she estimated
to be approximately 3 months) and she was symptoms free.
Eleven years later and that was in 1984, her father passed away and she
started to develop sleep disturbance again, she was taken right back to
Amanuel Hospital and was receiving unspecified injectable medication she
improved and was well on her feet again.
a. Past Medical illness: She mentioned that she had some kind of off and
on types of stomach problems back in seventies of which she was given
unspecified medications and she was cured completely, other than that
there is no any other medical or surgical illnesses.
b. Alcohol and other substance history: She drinks local Alcohol known
as “Tela” in some occasions, one small cup if she gets it, otherwise no
any other history of substance use.
V. FAMILY HOSTORY: No any psychiatric history in the close relative of
the patient or immediate family members. No any history of alcohol or any
other substance abuse. There is no any family history of personality
disorder. The Patient’s father passed away in 1984 E.C but the cause is not
clear since his death was sudden. Her mother passed away two months
back as a case of paralysis of one side of her body, she was admitted at Ras
Desta Hospital and passed away thereafter. Her siblings are 10 in number
four girls and six boys with her being the third child in her family. Two of
her siblings (males) died, one of whom died as a child, therefore, she could
hardly remember the circumstance of his death but the second brother died
 on accident as the patient claimed that he fell into the toilet (It is mentioned
in the HPI) . Though, the patient is single she believes that she has all the
support she needs from her family she also mentioned that she likes her
family. She denied any family history of violent behavior or substance
abuse.
VI. PERSONAL HISTORY(Anamnesis):
a. Perinatal history: The patient reported that her mother pregnancy by
her was planned wanted and supported, the pregnancy was a successful
one and no complication during pregnancy such as bleeding, or
infections. The pregnancy lasted until term and the delivery was normal
vaginal delivery at home and once again there was no any
complications during the delivery. The mother did not take any drug
during her pregnancy and there were no any defects at birth.
b. Early childhood: The patient as a child was breast fed and later on
when she could eat she didn’t have any eating problems. She had
normal sleeping pattern during childhood as well. Although she
developed to the expected milestones as her peers she claimed that she
learned to stand and walk later than expected (she heard from her
mother) but she couldn’t tell exact time at which she learned to walk or
stand.
c. Middle childhood: She started her school at age of 8 years old here in
Addis, and she reported that she was a good student, she was healthy
during this time as well, no history of trauma or any other illnesses
d. Adolescence: She doesn’t remember the onset of her puberty. She was
still a good student at school and she used to get between As and Bs in
her exam results. She didn’t have any habit of drinking alcohol or use
of any other drugs of abuse.
e. Young Adult: She maintain her academic performance until grade 12
at which time she claimed to have had some problem with study stress,
and when she failed to cope up with that she failed the grade 12 exam
as a result, she developed sleeping problem and was agitated
(mentioned in the past psychiatric history) she was subsequently taken
to Amunel hospital and was admitted there for a month and was
discharged thereafter symptoms free.
f. Adulthood:
1. Occupational history: She didn’t work any other work
outside her home than simple routine house chores, though she
mentioned that she once applied to the job at RAS DESTA
Governmental facility but unfortunately her application was
rejected, at that time she told the supervisor that “I am better
than all of you”. She claimed to have never had any other
attempt to apply for job.
2. Marital and relationship history: She never married and
when asked for the reason; she said “I decided to help family
instead after the death of my brother who was the primary
supporter of the family”.
3. Military history: She had no military experience nor was she
even interested in it.
4. Educational history: Since she started school at age of 8 she
was always doing well at school until grade 12 which she
failed claiming that she couldn’t cope up with the stress, and
she thereafter ended into some psychological disturbance
(mentioned in the past psychiatric illnesses). She then left
school. None of her close relative had graduated from the
college including her parents and siblings.
5. Religion: Both her parents were Orthodox and they were
permissive for her choice on religious education, there had
never been any dispute with her parents on that matter. She
had become Orthodox since childhood and never deviated
from that until now.
6. Social activity: The patient has many friends from both sexes
and she always spend some free time chatting and enjoying
coffee in groups. She denied any desire for isolation, there is
no any history of fear of public places or fear of other people.
B. MENTAL STATUS EXAMINATION:

1. Appearance: The patient is well dressed and appropriate to the

weather, tidy and clean, there is no use of accessory materials. She was
cooperative during interview and maintained good eye contact
throughout the interview, the gait was normal as well.
2. Motor Activity: The motor was normal, no any psychomotor agitation
or retardation, she was calm throughout the interview.
3. Speech: The speech was normal in terms of rate, volume and tone as
compared to my own, but excess in amount.
4. Emotions:
a. Mood: The patient said “I feel sad”
b. Affect: It was appropriate during the interview as I observed that.
5. Thoughts and contents: She has no flight of ideas or delusional
thoughts.
6. Perceptual disturbance: No hallucinations or any type of delusions;
she does not think that people are controlling or withdrawing her
thoughts, neither does she believe that her thoughts are being
broadcasted in the air. She has grandiose ideas as she said she was
better than the supervisor and everyone at work place in Rast Dest
where she applied and was rejected (It is mentioned in occupational
history).
7. Sensorium and level of consciousness:
a. Alertness: She was alert and conscious during the interview
b. Orientation: She knew what the day of the week it was during
the interview, she also knew the date the month and the year.
She said she was at St. Paul’s Hospital in the third floor at
psychiatric department.
c. Memory: Her remote memory is normal since she recalled
stress related to grade 12 back in 1973, her recent memory is
normal also since she told me what she ate the night before the
interview and her immediate memory was normal as well; the
patient could recall my name (interviewer) and my colleague’s
name after the interview.
 d. Concentration and attention: The patient can recite the names
of the days of the week forwards and backwards
e. Reading and writing capacity: She could write and read a
sentence in Amharic (she wrote and read, “My name is
Tadalech”)
f. Abstract thinking: The patient can explained clearly the
different between chair and table in terms of function and shape,
that the chair is for sitting and table is for putting things on, she
also said they both have four legs.
g. General knowledge: When asked, she said that the name of
Ethiopia Prime Minister is Hailmariam Desalegn and the Capital
city of Ethiopia is Addis Ababa.
h. Insight and judgment: The patient is well aware of her being
sick and she believes that coming to the hospital to see a doctor
is the best option for her health, she also knows that using
medication according to the doctor instructions is important for
the desirable outcome of her condition; therefore she has good
insight and judgment.

C. DIAGNOSIS

1. Axis I: Major Depressive disorder

2. Axis II: No any personality disorder
3. Axis III: No General Medical condition
4. Axis VI: Single (unmarried) and unemployed
5. Axis V: 70% mild symptoms

D. MANAGEMENT PLAN

a. Hypnotics: Diazepam (5-10 mg)

b. SSRIs: Sertraline (25mg) or Fluoxetine (15mg)
c. Psychotherapy
d. Sleep hygiene
Prepared by: Dr. Daniel Garang Aluk Dinyo (MD)
St. Paul’s Hospital Millennium Medical College
Addis Ababa – Ethiopia
Emails: danielalukdinyo9@gmail.com
danielalukdinyo9@yahoo.com
danielalukdinyo9@live.co.uk
Submitted to: Dr. Solomon (MD, Psychiatrist)

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