History

Patient Demographics
● Olive (de-identified), 60 years old Chinese lady
● Currently a housewife
● Married for over 30 years
● 1 daughter

Presenting Complaint
● Admitted yesterday (17/9/19) for ECT

History of Presenting Complaint

● Was diagnosed with severe anxiety disorder
○ Had symptoms including irritability, insomnia, anxiety for 1 year prior to diagnosis
○ Diagnosed in march 2018
○ No Symptoms of hyperthyroidism
● HISTORY GIVEN BY THE DOCTOR: Was diagnosed with schizophrenia last year
○ Not sure when and what are the symptoms
● ECT
○ Started since one year ago when she was diagnosed with schizophrenia
○ Done it more than 10 times already
○ Initially weekly -> 2 weekly -> 3 weekly -> now monthly
○ Currently on maintenance ECT
○ Latest one done yesterday morning
■ Intensity: 74%
■ GTC: 25 seconds
■ EEG duration: 22 seconds
● Currently well, all the symptoms have improved since the commencement of ECT
○ No chest pain, shortness of breath, sweating, palpitation
● Relevant negatives
○ No anhedonia ○ No distractibility
○ No guilty ○ No grandiosity
○ No low energy or mood ○ No flight of ideas
○ No poor concentration ○ No pressured speech
○ No loss of appetite ○ No thoughtlessness
○ No psychomotor activity ○ No delusion
○ No suicidal ideation/ attempt ○ No hallucination

Past Medical History

● Hypertension diagnosed around 30 years ago, on amlodipine, compliant to
medication, no side effects experienced, good control
● Hypercholesterolemia diagnosed a few months ago, on Simvastatin, compliant to
medication, no side effects experienced, good control
● At 20+ years old, had an appendectomy, hospitalised
● 30 years ago, undergone LSCS and delivered a premature baby due to hypertension
(baby was hospitalised for 1 month)

Family History
● Father passed away due to old age, mother has hypertension and diabetes
 ● 4 siblings, eldest
○ Some of them have hypertension
● 1 daughter
○ 29 years ago, married, healthy
● No family history of psychiatric illness

Medication History
● Amlodipine
● Simvastatin
● Medication for anxiety (sertraline)
● Olanzapine (underlying schizophrenia)
● No known allergies

Personal History
● Birth: no complication, SVD
● Development: normal
● Childhood: no illness
● Education: up to Form 5
● Work: after form 5 -> clinic nurse -> clerk -> housewife
● Hobbies: scroll facebook, do housework, seldom go out with friends

Menstrual
● Menarche at 10 years old, menopause for a few years already, not on medication or
supplements
● Regular, 3-4 days cycle, no menorrhagia, dysmenorrhoea only on 1st day
● Pap smear done a long time ago, normal results
● No HPV vaccine

Sexual
● Husband is the only sexual partner
● No STI

Substance use
● Only drinks alcohol once in a while when attending events (Guinness Stout)
● Never smoke, never take illicit drugs

Forensic History
● None

Premorbid personality
● She herself thinks that she is the person who likes to stay home
● Husband and friends think she is friendly and sociable

MSE (18/9/19 815am)

1. Appearance & behaviour

 a. Chinese female of the age of __, sitting on her bed in the ward, good hygiene,
well-groomed and of a normal body built and average height
b. Wore a blue outfit (Preparation for the ECT) over the usually green uniform
c. Jovial, good eye-contact, cooperative and very comfortable when speaking,
good posture while sitting
d. No psychomotor retardation, tremors, restlessness
e. Able to speak English and Mandarin
2. Speech
a. Normal rate, no poverty or pressured speech
b. Normal volume
c. Speech is not slurred
3. Mood & affect
a. Mood - euthymia
b. Affect - normal range, appropriate, congruent
c. Mood was not labile
4. Perception
a. No hallucinations
b. No derealisation, depersonalization
5. Thoughts
a. Form of thought
i. No flight of ideas, poverty of idea, tangentiality, derailment,
circumstantiality
ii. No neologism, incoherence
b. Thought content
i. No delusions or obsessions
ii. No suicidal thoughts
6. Insight
a. Good
7. Judgement
a. Good judgement
8. Cognition
a. Alert, conscious, oriented to time, place, person
b. Memory: There is signs of retrograde amnesia as the patient relies on the
husband to tell her about her symptoms
c. Concentration: Able to tell numbers in serial of seven
d. Abstract thoughts: similarities and differences of orange and apple