DEPARTMENT OF PSYCHIATRY

CASE WRITE UP

NAME: DINESH KUMAR KARUNAKARAN

MATRIX NO: BMS19096713

GROUP: 2

YEAR: 4

ACADEMIC SESSION: 2022-2023 DATE: 20/02/2023

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INDEX

1. PATIENT’S DETAILS
2. CHIEF COMPLAINT
3. HISTORY OF PRESENTING COMPLAINT
4. PAST PSYCHIATRY HISTORY
5. PAST MEDICAL HISTORY
6. MEDICATION HISTORY
7. FAMILY HISTORY
8. PERSONAL HISTORY
9. SOCIAL HISTORY
10. MENTAL STATE EXAMINATION
11. PROVISIONAL DIAGNOSIS
12. DIFFERENTIAL DIAGNOSIS
13. MANAGEMENT
14. DISCUSSION
15. CLINICAL PROBLEMS
16. PROGNOSIS
17. LEARNING OUTCOMES
18. REFERENCES

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1. PATIENT’S DETAILS:

Name : Mr. S
Age : 27-years old
Gender : Male
Race : Malay
Occupation : Unemployed
Marital status : Single

2. CHIEF COMPLAINT:
Patient presented to the clinic for follow-up.

3. HISTORY OF PRESENTING COMPLAINT:

Mr. S was a known case of mental disorder. Patient was

diagnosed to have Chronic Schizophrenia for 8 years. He denies
hearing voices and no visual hallucination. He was reported with good
communication, sleep, and appetite.

4. PAST PSYCHIATRY HISTORY :19 Years old

Patient was admitted to the psychiatry ward once due to

aggressiveness and stress because he was not compliant with his
medications (Olanzapine and Clonazepam).

5. PAST MEDICAL HISTORY :

No epilepsy or other medical conditions were reported.

6. MEDICATION HISTORY :
● Patient was initially taking Olanzapine and Clonazepam.
● IM Clopixol 200mg
● IM Orphenadrine 100mg
● Patient is now having Olanzapine 10 mg and Clonazepam 1mg.

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7. FAMILY HISTORY :
● Patient is currently staying with his father.
● Patient is single.
● He has no significant family history of schizophrenia.

8. PERSONAL HISTORY
​ a) Education history
- Completed SPM
​ b) Childhood History
- Nil
​ c) Birth History
- Spontaneous vaginal delivery with no complications.

d) Occupation

- Currently unemployed

9. SOCIAL HISTORY :
​ ● No significant relationship
​ ● No smoking
​ ● No drinking alcohol

10. MENTAL STATE EXAMINATION :

➔ General Appearance
◆ Patients appear neat with good personal hygiene.
◆ Patient is sitting comfortably on a chair.
➔ Mood & Affect
◆ Mood: Well and calm
◆ Affect: Euthymic and congruent with the conversation

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 ➔ Perception
◆ Patient denies visual hallucinations.
➔ Thought process and thought content
◆ Patient demonstrates a clear and logical thought process
with no evidence of disordered thinking.
◆ Patient denies any delusion, phobia, obsession and
compulsions.
➔ Orientation
◆ Oriented to time, place and person
➔ Concentration
◆ Nil (subtract 7 out of 100?)
➔ Memory
◆ Immediate : Nil
◆ Recent : Nil
◆ Remote : Not able to mention the correct diagnosis date.

➔ Abstract & Judgment

◆ Not able to access.

➔ Insight
◆ Patient is aware of his diagnosis and knows to consume his
medications in order to get better

11.PROVISIONAL DIAGNOSIS :

● Chronic Schizophrenia

12. DIFFERENTIAL DIAGNOSIS :

● Schizoaffective Disorder
● Delusional Disorders
● Major Depressive Disorder

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 ● Borderline Personality Disorder
● Substance-induced psychotic Disorder

13. MANAGEMENT DECIDED :

Antipsychotics (Mainstay of pharmacological treatment in

schizophrenia)

● Initially given Olanzapine + Clonazepam

Due to non-compliance
● Depot injection of IM Clopixol 200 mg (side effect of oculogyric
crisis/dystonia)
Patient developed oculogyric crisis/ acute dystonia
● Given IM Orphenadrine 100 mg (muscle relaxants as antidote of
Clopixol)
● Later on Clopixol was reduce to 100 mg, and given Olanzapine
10 mg, Clonazepam 1 mg at night
● Currently patient was on Olanzapine 10 mg and Clonazepam 1
mg except Clopixol was no more given to him

14. DISCUSSION :

This was a known case of schizophrenia of a 27 years old Malay male patient
presented to the Hospital Kuala Lumpur for regular follow up and the patient
was diagnosed to have Chronic Schizophrenia for 8 years.

15. CLINICAL PROBLEMS

● One episode of aggressiveness
● Oculogyric crisis

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● Acute dystonia
➔ Socio- demographic factors
​ ● Relatively higher non-adherence in the young population
​ ● Positive association between unemployment and
non-adherence. Younger age at onset.
​ ● Early onset of psychosis needs prolonged duration of
medications which would lead to the increased number of side
effects leading to non-compliance.
​ ● This patient has early onset, so it could be a factor for her
non-compliance.
​
➔ Poor insight
● Unaware of their illness and refusing the requirement of
medication.

A study of attitude toward medication and reasons for

Non-compliance in patients with schizophrenia Reasons for
compliance :

​ 1) Perceived daily benefit

​ 2) Family belief
​ 3) Relapse prevention
​ 4) pressure / force

Reasons for non-compliance :

​ 1) Denial Of Illness
​ 2) Financial Obstacles
​ 3) Access to treatment problems
​ 4) Distressed by side effects
​

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 This study found that the most significant reason for compliance with
the treatment is by perceived daily benefit followed by other factors and the
most significant reason for noncompliance is the denial of illness followed by
other factors.

This patient seems to not have many significant factors associated with
reasons for noncompliance, only issue seem to be side effects. So targeting
the treatment on reducing her side effects would be a useful strategy.
Biopsychosocial rehabilitation with new help and advice could increase the
chance of bringing this patient into remission.

➔ Treatment in Non-compliance :

Address the reasons for the non-compliance

​ ● Changing medication regime with fewer side effects

​ ● Psycho-educational programmes on compliance
​ ● Active involvement of the relatives and significant others
​ ● Drop-in community centres and other support provided by voluntary
organisations are often helpful
​ ● Consider interventions offered by other professionals ( eg;
occupational therapy, physiotherapy ) with problems of poor sleep,
hygiene, anxiety management.
​
16. Prognosis :

Associated with Better Prognosis Associated with Worse Prognosis

- Later onset - Early onset

- Good social support - Poor social support
- Positive symptoms - Negative symptoms
- Mood symptoms - Family history

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- Acute onset - Gradual onset
- Female - Male many relapses
- Few relapses - Poor premorbid function
- Good premorbid functioning - Comorbid substance use

I think this patient will have poor prognosis as he unfortunately has

many factors on her poor prognostic side than good prognostic side. But
if we could intensify the biopsychosocial approach with targeted and
planned manner, we could change this prognosis to a good one.

17. Learning outcomes :

​ 1) How a psychiatric illness can change an individual’s life.
​ 2) How complex and multifactorial are often the problems associated
with psychiatric illness.
​ 3) How difficult and challenging the management of cases with chronic

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 18. Reference :
​ ● Harrison, P., Cowen, P., Burns, T., & Fazel, M., 2018. Shorter Oxford
Textbook of Psychiatry. 7th ed.
​ ● Kaplan and Sadock’s. Synopsis Of Psychiatry., 11th ed.
​ ● Ivatury Sarath Chandra et al., Attitudes toward Medication and
Reasons for NonCompliance in Patients with Schizophrenia., Indian
Journal of Psychological Medicine., july 2014.

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