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Mental Status Examination

Mental Status Examination

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Published by drhusnafadzil

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Published by: drhusnafadzil on Jun 19, 2009
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FARAH HUSNA MOHD FADZIL040100848Post-Test Psychiatry11 Jun 2009
MENTAL STATUS EXAMINATION
I. PSYCHIATRY HISTORY
A. IDENTIFICATION
Name:Mr ZAge:46 years oldSex:MaleMarital Status:Married with 3 childrenReligion:IslamEducation level:Master Degree in Mechanical EngineeringAddress:Kangar, PerlisOccupation:Lecturer in local universitiesSource of referral:Patient
B. CHIEF COMPLAINT
Patient came to the psychiatric clinic on follow up and to continuemedication he received since 2002
C. HISTORY OF PRESENTING ILLNESS
Previously, Mr.Z was apparently fine until the first symptomsappeared in year 1987 when he was working at Kolej PengurusanPenerbangan. They were manifested as several weeks of dramaticmood changes, feeling high of excitement, overactivity, suffered fromlack of sleep, being restless and having an unacceptable behaviour . These were followed by few days of depression during which he slept alot, felt lost of energy and not interested in anything. The symptoms of elation and depressive alternately appeared and within few months,patient was back to his usual self again before having the next attackfew years later.During his energetic periods,Mr. Z was optimistic,self-confidentand had lots of ambitious plans. He claims to have a good handwriting
 
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that he was awarded the best handwriting. He wants to be the richestman by producing a new helicopter which is designed by him.Subsequently he realized that a big project such that couldn’t be doneindividually. As a result he stops the project eventhough he haddesigned the model of helicopter. Patient also claimed he wanted topropose singer/actress, Erra Fazira for marriage. At this state, patientalso said that he behaves impulsively and his sexual desire increasedimpulsively.He also claimed spending large sums of money on unnecessarythings such as treat his friends at any expensive restaurant for noreason.Patient also claimed giving RM2 to every person/strangers hemet.During his depressed periods, he often stays in bed all day due tofatigue circumstance,no interest in any activities,feeling down anddepressed.He also had a thought of suicide but never had any attemptof suicidal.Although patient denied any spiritual involvement regarding hiscondition, Mr. Z’s parents and uncle who noticed his ‘changes’referredhim to ‘Bomoh’ as they believe that patient was being possessed bysome spirit. Patient claimed that he was treated ridiculously by the‘Bomoh’. Mr. Z denied any spiritual help regarding his condition. Hisparents and uncle who noticed his ‘changes’, bring him to get helpfrom ‘Bomoh’ as they believe that Mr. Z being possessed by somespirit. Patient then claimed that he was treated ridiculously by the‘Bomoh’. He also believes that his uncle had a bad intention towardshim from the time when his uncle said he was crazy.Patient was thenbrought to Hospital Lam Wah Ee, Penang by his parents and he washospitalized there.Subsequently, patient was frequently admitted in differenthospital due to same episode.In 1991, patient was hospitalized due tohis manic state and then he was put on medication. In September2002, patient was studying in France and he ran out of medicine. As aresult, the same episode occurred in the same year that patient had tobe hospitalized in a Psychiatric Hospital in France.Patient was sent backhome in same year and continued his medication at Hospital TunkuFauziah,Perlis until today.
D. PAST MEDICAL & PSYCHIATRIC HISTORY 
Patient had hypertension and diabetis mellitus. He had been follow uptill now at outpatient department of HTF.
E. FAMILY HISTORY 
Grandmother had psychotic symptom after giving birth but never seekmedication
 
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F.PERSONAL HISTORY 
CHILDHOOD HISTORYPatient had normal development during childhood and teenage years.He continued doing master and allegedly dropped out due to mentalillnessSCHOOL HISTORYHe identify himself as an active student where he always involved inlots of school activities.RELIGIOUS BACKGROUNDHe came from a religious family background.MARITAL HISTORYMarried with 3 children :i)13 years old daughter,ii)11 years old soniii)6 years old daughterPatient claimed his wife and children understands his problem andthere is no other significant problems in his marriage.OCCUPATIONAL HISTORYClaimed not having problem with his occupation, he feels comfortableat his working place as all his colleges understands him. DRUGS, ALCOHOL & TOBACCO HISTORYNil 
MENTAL STATUS
A.
APPEARANCE & BEHAVIOR
a.Patient appears well dressed,excited,and talkative. 
B.GENERAL DESCRIPTION
He is well dressed with casual clothing
C.SPEECH
He speaks Malay rapidly, jumping from one idea to another( flight of ideas), spontaneously answering
D.MOOD & AFFECT
Euphoric and easily distracted.
E.
THOUGHT
Logical and goal oriented

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