Case Study

1. History Taking : History is obtained from the patient.

2. Identifying Data
a) Name of patient : Wai Ming Kwan
b) Sex : Female
c) Race : Chinese
d) Age : 60
e) Religion : Cristian
f) Marital Status : Divorced
g) Language Spoken : English and Mandarin
h) Ward : 14
i) RN : WPO 59044
3. Reasons for Admission
Source for referral : Form 5 + P57
Reason for referral : Moved out of the church
Stays by herself
Family unable/doesn’t care for her
Found wondering using foul language, shouting, undressing in the
public
4. History of present illness
i. Chief complaints : Wondering around stripping herself naked in the streets.
ii. Type of onset : Relapse
iii. Duration : After her previous admission which is in 2012
iv. Precipitating : Loss of job
factors : Divorce
v. Ability for work : She cannot work because have some issue coping with collogues
and her boss
vi. Sleep pattern : Patient has normal sleep pattern
vii. Appetite : Normal Appetite completes full plate meal during meals time.
viii. If relapse present : Relapse present several times.
treatment patient Patient is on following medications
is on T. Lithium Carbonate 150mg OM
T. Lorazepam 1mg ON, 1 mg PM, 2mg ON
T. Orazepine 15mg ON,
IM Fluxol 20mg monthly
T. Amilodipine 50mg OD,
T. Simvastatin 20mg ON,
T.Epilium 400mg BD
Syrup Lactulose 15mls PRN

5. Family history : No presence of any mental illness in the family

6. Family life and :  The husband was the head of the family
relationship with family  The family was having marital issues where the husband
and the patient ended up getting divorced when the son
was 13 years old in 1991.
 Patient claimed that having some quarrels with her sister
but does not want to talk about it.
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 Patient refused to talk about her husband and claims it is
personal when asked further about her husband
 Patient’s relationship with her son was good.
 Patient was having some internal issues with the husband
7. Personal History
a. Date of Birth : 31.01.1958
b. Place of birth : Hospital Kuala Lumpur
c. Infancy and
childhood
Birth : Spontaneous vaginal delivery with no complications
Milestone : Started walking at 11months old, others she cannot recall.
Neurotic traits : Patient was short tempered, some of the siblings were scared of
her
d. Education : Patient studied at an English School
Passed O’ Levels and SPM
Patient liked school and never stopped till se finished.
Patient had many boyfriends than girls
Patient liked singing and dancing in the school choir
Patient had no problems with teachers
The patient ‘s ambition was to work in a big company

e. Occupation : She worked as a secretary for a year

Patient liked the job since she had trained for it in college.
She attended for the course in Jalan Ipoh, Kuala Lumpur
She was paid around RM 1500
Patient left because she wanted to care for her son and was not
happy with the boss
Patient said she sometimes quarreled with the boss and co-
workers if they provoked her.

f. Menstrual History
Age of Menarche : 12 years’ old
Patient was not prepared for menarche, her elder sister had to
help her
Regularity of : Normal cycle for 7 days
menstrual cycle Her change of mood will be present before her periods but will be
fine post period
Menopause : It started at the age of 45 years old.
She was feeling hot all the time
She got into the amenorrhea phase
g. Sexual history : Patient claimed she dated a few boys in her 20’s
Her first love was the husband whom she later married
h. Marital history
Husband ‘s Name : Hoo Jung Ming
Age : 62 years old
Occupation : Taxi Driver
Place of birth : Cheras
Patient was committed in a marriage by love marriage
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She dated her ex-husband for about 3 years and got married
when she was 26 years’ old
Patient says the husband cheated her so they had to divorce
i. Children Patient was only pregnant once with no any history of abortions
Patient was blessed with one son
Name : Wai Jeng Hoo
Age : 28 years
Sex : Male
Marital status : Single
Occupation : Works in Hong Kong
Relationship with : Broken after her admission
mother
j. Socio-cultural
Background
Place of residence : Cheras, Selangor
Stayed in a rented house
Patient lived alone after son left to Hong Kong
Religion : Christianity
Patient prepared all the meals for herself and son
Language spoken : Mandarine
at home
k. Habits : Patient is an ex-smoker, used to smoke 10 sticks a day.
Patient was also a drug and alcohol abuser
Patient also used to go clubs with friends
l. Previous : First admitted in 1999 in HKL for mental breakdown after
psychiatric attack quarrelling and shouting with people
She was given treatment of antipsychotic, antianxiety drugs
which she did not comply
Characters abnormalities noted by family was shouting using foul
language depressed, not enough sleep and poor appetite
m. Previous Medical/ : Hypertension on treatment
Surgical History No presence of any surgery in her past

8. Premorbid personality
Character : Hot tempered, extrovert, jealousy
Habit : Eating: Poor Appetite
Sleeping: do not have any signs of insomnia. Sleeps throughout
the night and does not wake up in between
Mood : Self-depreciating, fluctuating,
Energy : very initiative
Defense Mechanism : repression where keeping her anger with her boss.
Sublimation
9. Mental Status
Examination
General appearance
Facial expression : Smile
Body built : Weight: 64kg
Height: 158 cm
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Short and thin
Posture : Normal
Gait : Relax, normal gait
Dress : Uniform- clean, non-smelly
Personal care/Hygiene
Oral hygiene : Teeth appears white with no smell from the oral cavity. Loose
dentures which hinders speech sometimes. Dentures appears
yellowish with carries
Hand hygiene : Patient washes her hand before and after food and after toilet
visits
Clean and short fingernails kept
Bath : Took shower in the morning. No body odor presents with talcum
on face
Hair : Kept short and well kempt
External Injuries : No presence of tattoo
No deformities present
Presence of old scars at booth feet no presence of any fresh
wound

General Behaviors : No stereotypic action

Cooperative following instructions from the staff nurse and PPK
Relaxed and calm
Maintains eye contact
No echolalia or echo pyrexia seen
No mannerism
Sits with straight body posture
Isolates herself from other patients
Sleep : What time do you sleep?
‘ I sleep at 9pm ‘
What time do you wake up?
6am
No complaint of insomnia
Do you wake up in the middle of your sleep?
No

Appetite : Do you finish your food during meal time? What is your favorite?
‘Yes. I like mee goring with coffee. ‘
Finishes 1 full plate of mee goreng with 1 full cup of coffee

Mood and Affect

Mood good : How are you feeling today?
Affect ‘fine, I slept well’ said with smile
How you feel when your son visits you?
Happy lah! Says with excitement

Speech
Content
Grandiose Delusion
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Money : Do you have bank accounts?
‘No, I don’t have money’
Power : Are you the leader here?
No, I am normal
Talent : Can you see the future?
Give me your hand I will look at your future’
She believes that she could read out our future with the creases
in our palm

Paranoid Delusion : Is anyone trying to hurt you?

No
Hallucination
Auditory delusion : Do any voices talk to you?
‘No’
Visual delusion : Do you see people that talks to you?
‘No’

Reference
TV : Did you appear on the TV?
‘No’
Radio : Did they talk about you on the radio?
‘No’
Newspaper : Did you read about yourself in the newspaper?
‘No’

Intellectual function
Memory
Past : Where did you study during primary school?
SJK Chung Hwa
Where did you study for your secondary school?
‘catholic school with O’level Grade 3 pass
What did you do after secondary school?
‘I went to learn up for a secretory course in Jalan Ipoh’
Did you work as a secretory then?
Why did you stop?
‘I could not get along with my boss’
Present : What did you do on Hari Raya?
‘We had nice food.’
Recent : What did you have for breakfast?
I had bread and coffee.’

Orientation
Place : Where are you currently?
‘Ward 14, Hospital Bahagia.”
Person : Who am I?
‘Student’
Time : Is it Day or Night now?
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‘Afternoon’
Concentration : Can you count from 10 backwards?
’10,9,8,7,6,5,4, 3...’
Attention : Can you minus 1 from 100?
‘Yes 99.’
Patient has concentration and attention.
Orientated to time place and person.
General Knowledge : Do you know our nasional flower?
‘Bunga Raya’
Do you know what hospital is this?
‘Hospital Bahagia Ulu Kinta’
Abstract : Do you know what is a snake?
‘It will bite’
Do you know what is a rod?
‘It is not alive.’
Judgement : What will you do if someone collapses in the ward?
‘Call the nurse lah.’
Good judgement, patient knows whom to call for help
Insight : Why did you get admitted?
‘Because I quarrel with my sister. She sent me here.’
Bad insight because patient not aware she is sick
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Physical Assessment

Integument

 Skin: The client’s skin is uniform in color, unblemished and no presence of any foul
odor. He has a good skin turgor and skin’s temperature is within normal limit.
 Hair: The hair of the client is thick, grey hair is evenly distributed and has a variable
amount of body hair. There are also no signs of infection and infestation observed.
 Nails: The client has a light brown nails and has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the fingers the
nails return to usual color in less than 4 seconds.

Head

 Head: The head of the client is rounded; norm cephalic and symmetrical.
 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency and with
no presence of nodules or masses.

Eyes and Vision

 Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned
and showed equal movement when asked to raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be very minimal.
 Eyelids: There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
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o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
o When assessing the peripheral visual field, the client can see objects in the
periphery when looking straight ahead.
o The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing

 Ears: The Auricles are symmetrical and has the same color with his facial skin. The
auricles are aligned with the outer canthus of eye. When palpating for the texture,
the auricles are mobile, firm and not tender. The pinna recoils when folded. During
the assessment of Watch tick test, the client was able to hear ticking in both ears.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions
 Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction
of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft,
glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist
and slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a
more irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.
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 Neck:
o The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during
swallowing but are not visible.

Thorax, Lungs, and Abdomen

 Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full
and symmetric expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory excursion. The client manifested
quiet, rhythmic and effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips are of the same
height.
 Abdomen: The abdomen of the client has an unblemished skin and is uniform in
color. The abdomen has a symmetric contour. There were symmetric movements
caused associated with client’s respiration.
o The jugular veins are not visible.
o When nails pressed between the fingers, the nails return to usual color in
less than 4 seconds.

Extremities

 The extremities are symmetrical in size and length.

 Muscles: The muscles are not palpable with the absence of tremors. They are
normally firm and showed smooth, coordinated movements.
 Bones: There were no presence of bone deformities, tenderness and swelling.
 Joints: There were no swelling, tenderness and joints move smoothly.
 Case Study
Bipolar Disorder
Manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity
levels, and the ability to carry out day-to-day tasks.

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy,
and activity levels.

These moods range from periods of extremely “up,” elated, and energized behavior (known as
manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less
severe manic periods are known as hypomanic episodes.

 Bipolar I Disorder— defined by manic episodes that last at least 7 days, or by manic symptoms
that are so severe that the person needs immediate hospital care. Usually, depressive episodes
occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features
(having depression and manic symptoms at the same time) are also possible.
 Bipolar II Disorder— defined by a pattern of depressive episodes and hypomanic episodes, but
not the full-blown manic episodes described above.

Sign and Symptoms

People having a manic episode People having a depressive

may: episode may:

 Feel very “up,” “high,” or  Feel very sad, down, empty, or

elated
 Have a lot of energy
 Have increased activity levels 
 Feel “jumpy” or “wired”
 Have trouble sleeping
 Become more active than usual
 Talk really fast about a lot of
different things
 Be agitated, irritable, or
“touchy”
 Feel like their thoughts are 
going very fast
 Think they can do a lot of
things at once
hopeless
 Have very little energy
Have decreased activity levels
 Have trouble sleeping, they may
sleep too little or too much
Feel like they can’t enjoy
anything
 Feel worried and empty
 Have trouble concentrating
 Forget things a lot
Eat too much or too little
 Feel tired or “slowed down”
 Think about death or suicide
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 Do risky things, like spend a lot
of money or have reckless sex

Tests and Procedures

 Bipolar I disorder is a clinical syndromal diagnosis based on history and mental status exam,
without a diagnostic laboratory test.
 Tests to assess etiologic factors include CBC, BMP, LFTs, TSH, B12, folate, vitamin D, RPR,
blood alcohol level, urinalysis, and urine toxicology.
 Obtaining a detailed history is paramount in diagnosis.
o Many patients with bipolar I disorder will present with a depressive episode; it is
important to ask about past manic/hypomanic symptoms (mood swings, episodes of
increased energy and decreased need for sleep).
o It is also important to ask patients’ family members or friends about past
manic/hypomanic symptoms, since patients often lack insight regarding
manic/hypomanic symptoms or may not remember them clearly (especially if the patient
is currently depressed).
o Patients in a manic or mixed state will often be agitated and unable to give a coherent
history; additional information should be obtained from family members or friends.
o It is important to ask about suicidal ideation and substance abuse.
o Eliciting a family history of bipolar disorder is also helpful given the strong genetic basis of
bipolar disorder.
o Screening questionnaires, e.g., the Mood Disorder Questionnaire (MDQ), can be filled out
by the patient; it is helpful to have a family member fill one out as well, since patients
often do not self-report manic symptoms.

Prognosis

The prognosis of the patient is good.

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CASE STUDY
HBUK

Name: Denesha Kaur a/p Gopal Singh

Student ID: 17039603
Group: G201704
Semester: 5