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3rd CASE WRITE-UP
HAMZAH BIN NAJID 123149 4th YEAR MEDICAL STUDENT PSYCHIATRIC POSTING
SUPERVISOR: ASSOC. PROF. DR. BRIAN HO
due to aggressive behavior on the day of admission. Because of the stress. and currently on T. But he mentioned that he just did his work as usual because he afraid he : : : : : : : : : : Mr. He claimed that he tried to avoid hearing the voices by closing his ears. there was no one around him. He also mentioned that when he heard the voices. Haloperidol and T. He claimed that on that day. On the day of admission.Preliminary Identification Name Age Marital status Sex Address Occupation Language Race Date of admission Date of clerking Chief Complaint My patient was admitted to the ward via A&E unit. who was a known case of mental illness since 2 years ago. was admitted for the second time in HKL psychiatric ward. and had been followed-up at HKL psychiatric clinic. he started to hear voices which were a woman’s voice. A. but it failed. accompanied by his wife and employee. He was previously well until 2 days prior to admission where he mentioned that he was very stressed because of heavy workload. He heard the voices during day time. Lorazepam. A 44 years old Married with 3 children Male Pantai Dalam Accountant clerk Malay Malay 18th July 2007 19th July 2007 . he had a lot of works to be finished. he went to work as usual. who always whispered to him to relax and be patient. History of Presenting Illness My patient is Mr.
or suicidal ideation. A also denied having any other hallucinations such as thought echo or discussing about third person. he also experienced low mood in the past two days before admission. However. which was 3 kg in two days. he was brought to the hospital by his wife and employee. . about 3 o’clock in the evening. he only could slept at 1 or 2 o’clock in the morning. He also claimed that in the past two days prior to admission. whereas he usually woke up at 8. However. his manager persistently pushed and pressured him to work faster but he refused because he afraid making mistake. He did it not only because of the voices. he will play football with his friends. He also denied having any manic or anxiety symptoms. Then. he denied feeling guilty or worthlessness. He denied having financial or marital problems.might make mistake if he do it faster. loss of concentration. delusional preference or thought alienation. He also complained of lethargic where he thought it was because of not enough sleep. He claimed that it only because of his works. he heard the same voices which asked him to crush down the computer. He also damaged his computer altogether. He claimed that usually after work. Unfortunately. He also claimed that he had difficulty in sleeping where he mentioned that in the past two days before admission. his employee keep pushed and pressured him. and there was no other stressor. he had loss his appetite and his weight.30 am. He mentioned that during that time. He also did not go for follow-up because he was too busy with his works. He also claimed that he had loss his interest on his hobby which is playing football. He claimed that he need break for a while and could not sit the whole day. he stopped taking his medication since two months ago because he felt he already well and healthy. his manager managed to avoid it and no injury occurs. Then his manager immediately called his wife and asks her to come to the office. He denied doing any other harm to his employee. Mr. After he had calm down. He also denied having any delusion of control. just before the incident. Fortunately. whereas he usually sleep at 11pm. but it also because of his temper to his employee. Especially because of his work is arranging clients’ accounts. while his employee asking him about works. about 4. Furthermore. According to the patient. He also claimed that he woke up early. According to him. The manager also asked the other workers to calm him down. suddenly he could not control his temper and throw his monitor’s computer towards his employee. he only took fruits during his lunch and dinner.
He never underwent for any surgery before. He claimed that after being discharged. His father had passed away due to motor vehicle accident when he was a baby. he claimed that it was good and they were close to each other. He mentioned that in the 1st admission. There was no history of electro-convulsive therapy or depot injection. During the interview. A denied taking any other drugs. he unable to recall the medications that he had at that time. substances or alcohol. His mother passed away when he was 9 . Then he had been followed up at HKL psychiatric clinic until 2 months ago where he had stop going for follow-up by his own decision. Past Psychiatric History This admission was his 2nd admission to psychiatric ward. His 1st admission was in 2005 where he had been admitted to HKL psychiatric ward. Mr. About his relationship with his wife and children before being admitted. Family History There was no history of psychiatric illness running in this family. hypertension or heart diseases. and started his own mechanic’s workshop. He had been warded for one week and the symptoms were resolved shortly after treatment. he claimed that he still can go to work like usual even in stressed condition.Regarding his work during before being admitted. asthma. he wanted to stop working his current jobs. Past Medical / Surgical History He had no chronic medical illness such as diabetes mellitus. he kept asking for letter to allow the release of his EPF funds. he also became stressed because of works and heard voices for three days before being admitted. However. The admission was similar with this current admission.
he kept his jobs until at the age of 25. he denied having any persistent depression symptoms. Adulthood He started working at the age of 18 as a mechanic. He loved to play football and also others outdoor activity. He had many friends at school and also at home. After that. Middle childhood (ages 3 to 11) He mentioned that he went to primary school just like any other child. he and his siblings still support each other. Later childhood (from pre puberty through adolescence) He went to secondary school until form 5. After that. However. After form 5. He had no discipline problems. he stopped studying and started working as a mechanic at his friend’s father workshop. He claimed that even until now. Past Personal History Prenatal History According to him. Regarding his relationship with parents and siblings. his uncle was the one who take care of him and his other siblings. His academic level was average. His development milestones were normal.years old due to unknown causes. He claimed that he had good relationships with girls and had many friends. he claimed that he had good relationships with other kids at his age. He claimed that his mother passed away when he was in standard 3. he claimed that it was good. He also denied involving in any gangsterism. except with his father as he could not even remember him. He also likes to read story books. After working as a security guard for 15 years. he changed his job as a security guard at a bank. He also denied that he was a hot-tempered person or mood labile person. His siblings are still alive and all of them were healthy. His . He claimed that he was active in sports and cocurriculums. Both of his parents did not have any chronic medical illness. he was delivered normally during birth and there was no birth complication. he had been offered to be an accountant clerk by his employee and he kept his job until now. and will help if anyone of them is in trouble. His academic results were average. Early Childhood (through age 3) He was breastfed until the age of 2. About his social relationship.
he was not in a good term with his employee. Current Social History Now. Premorbid Personality He described himself as an average and responsible person. He also denied taking any illegal substances. he claimed that he always stresses since 2 years ago but he still can cope with it. Regarding his coping skill in handling problems. He claimed that he is average in following the religion. Currently he is happy staying with his family. He claimed that it was because his employee always gives him extra works. However. He married at the age of 30 and now he has 3 children. About his works. Regarding his social relationship. he mentioned that every time he had a problem. He works as an accountant clerk at a bank. He is a smoker since 25 years ago. he will try to be patient and think about another better solution. who smoke about 3-4 cigars per day. he claimed that since two and a half year ago. His wife is a nurse at O&G unit in Klang Hospital and she goes for work by using public transport. He did not have any serious financial problems. He seldomly shared his problems with the others even with his wife. There was no history of sexual promiscuity. He denied having any sexual or marital problems.salary was about RM1300 and he claimed that it is enough to support his family. . He did not take alcohol or self-prescribed drugs. he had a lot of friends and always socializing with them especially at the evening where he goes to play football with them. he lived in his single storey-terrace house at Pantai Dalam with his wife and 3 children.
His hygiene status was fair and he was not smelly. and short. he seemed having low mood during the interview. who is wearing only hospital’s pants and pair of slippers. Rapport was easily built and he was co-operative towards the examiner.MENTAL STATE EXAMINATION General Appearances My patient is a middle aged Malay gentleman. His speed and amount of speech were normal. His hair was straight. thin with dark brown skin. There was no abnormal involuntary could be seen. with a middle built body. He claimed that he was in low mood because he worried about his EPF funds as he wants to quit his current job just after being discharged. Eye contact was good. However. On the interview. He claimed that once he admitted to the ward and took medications. . His affect was restricted but appropriate. but not well comb. Speech He spoke Malay very well. my patient rated his mood with 3 out of 10. He was not well groomed. Mood & Affect During the interview. he came voluntarily after his name was being called. the voices will disappear. Perceptual Disturbances He denied having any hallucinations during the interview. his speech was slow in volume and monotonous. There was no manic or anxiety symptoms. However. non-curly. with height which is about 170 cm and weight is about 60 kg.
or loosening of association. Cognition Orientation During the interview. He knew that he was in HKL psychiatric ward at the 1st floor. All of his thought during the interview was of his own. There was no thought block. or thought broadcasting. and person. and with meanings. or preservation. Conclusion: His orientation was intact. place. thought retardation. thought withdrawal. Flow During the interview. understandable. Possession There was no thought insertion. or overvalued ideas during the interview.Thinking Form His form of thinking was normal. his flow of thinking was normal. he was orientated to time. preoccupations. He also recognized and knew the name of the doctor who is in charge for him. He also knew the correct day and date of the interview. Attention & Concentration He was able to do the serial 7 test in 80 seconds without do any mistake. Conclusion: Memory For immediate memory. Content He denied having any delusions. preservation. There was no flight of ideas. . he could recall 7 digits forwards (5-2-9-7-1-8-3) and 5 digits backward (92-7-1-5). His attention and concentration were intact.
how much will get for the balance? He answered RM 2. Arithmetic: He could answer simple arithmetic problems without problem. You want to 5 eggs. he could recall three objects (cloth-car-bread) after three minutes correctly. Information & Intelligence Comprehension: He could understand my questions very well and answered it properly. You have RM 5 note with you. General knowledge: He was able to name all the Malaysian’s prime ministers. Abstract thinking Proverb test: He answered correctly all the proverbs given as below.For recent memory. So. and his home’s address very well. His information and intelligence was generally fair and concordance with his educational level. ‘Kaki bangku’ = someone who do not know how to play football ‘Cakar ayam’ = someone with bad handwriting ‘Buah tangan’ = present for someone Similarity: He answered correctly all the similarities given as below. ‘Pilllow – Blanket – Cake’ ‘Car – Van – Pen’ (The price of an egg is 45 cents.75 correctly) Vocabulary: Conclusion: His vocabulary in Malay was good. For remote memory. and Parameswara who was the first person to find Malacca. the United States . ‘Bicycle – Motorcycle’ = Transportation ‘Goat – Cow’ = Animals ‘Pen – Pencil’ = Stationeries ‘Spinach – Cabbage’ = Vegetables ‘Apple – Orange’ = Fruits Differences: He could pick up the difference between things such as. identification card number. he could remember his phone number. Conclusion: His memory was well intact. current prime minister.
‘Goat – Pants – Shirts’ ‘Apple – Orange – Curtains’ ‘Chair – Necklace – Table’ Conclusion: Judgement Social judgment: Test judgment: Personal judgment: ‘What will you do if you see someone is smoking in a cinema?’ “I’ll tell him either to stop smoking for that time or smoke outside. However. He could identify his early symptoms which are stress and auditory hallucinations. His judgment was intact. he will comply with his medications and will not miss his follow-up. He already thought about quitting his current job and starts his own business. He also knew that the stressor was all about his works. Conclusion: His insight was good.” ‘What will you do if you are being discharged today?’ “I’ll go and rest at home first. before this admission. His abstract thinking was intact.” Conclusion: Insight My patient aware about his illness but he did not remember the diagnosis for it. he claimed that he purposely stopped taking his medication and going for follow-up because he thought that he was already well. He regretted about that and he promised after this admission. Tomorrow I’ll meet my employee to ask for quitting the job. Physical Examination .” ‘What will you do if you see a stamped postcard nearby the road?’ “I’ll take the postcard and put it into post-box.
Loss of appetite.My patient is a middle-aged. Temperature Pulse rate Respiratory rate Blood pressure : 37°C : 72/minute : 18/minute : 114 / 74 mmHg Examination of cardiovascular system.Sleep disturbances .Low mood .Auditory hallucination for more than 1 day and less than 1 month . central and peripheral nervous system was unremarkable.Loss of interest to do his hobby . Provisional Diagnosis Brief Psycotic Disorder Points for: . The vital signs were.Patient was able to full return to premorbid level of functioning as he continue his work like usual after the first admission two years ago Points against: . respiratory system. There were no signs of hyperthyroidism or hypothyroidism.Presence of auditory hallucinations (psychotic features) Point against: . with fair hydration and hygiene status. loss of weight . middle built.Duration of the symptoms was less than 2 weeks . thin Malay gentleman.The presence of mood symptoms Differential Diagnosis Major Depressive Disorder with Psychotic Features Points for: .Disorganized behavious (aggressive behaviour) . gastrointestinal system.Always feels lethargic .
he more concerned and always talked about the auditory hallucination rather than the mood symptoms. infections. Investigations Biological Full Blood Count – to look for any underlying medical condition such as anemia. to identify any others precipitating factors and stressors. and assess the relationship between them. or platelet deficiency. I made the diagnosis is because according to the patient complaint. identify and confirm the precipitating factors. and the management that had been done. Also to obtain baseline value before starting the treatment. even the duration of the mood symptoms did not fulfill with the one in DSM-IV. clarify the history. and also to assess the relationship between the patient and the family members. Treatment . look at the history. the social and occupational function of patient in between the admissions. as far as I am concern. it is important for us to take it into consideration because it might affect or change in the management.* For the provisional diagnosis. However. Liver Function Test – baseline investigation before starting the treatment Renal Profile – baseline investigation before starting the treatment Psychosocial Trace his old notes to confirm about his first admission. to get more detailed history especially about his premorbid personality. Interview his employee regarding his works. Interview his family members especially his wife to clarify and confirm the history.
and parkinsonism. tardive akathisia. The reasons I chose this drug is because it has less extra-pyramidal side effects. When the patient has stabilized. I would like to monitor the side effects of these drug especially the extrapyramidal side effects such as acute dystonia. Anti-psychotic which is Respiridone (atypical antipsychotic). I chose SSRI because it has less side effects of cardiotoxicity. The reasons I chose this drug is because it can treat the agitation in very short duration. I would like to tell the patient that only uses this drug when necessary. as the patient presented to the ward acutely. This will help the patient’s sleep problems. Other than that. it also helps his wife because his wife works at night shift and she might not able to monitor and make sure the patient take medication accordingly. However. less anti-cholinergic side effects. this drug is just to stabilize the patient because this drug has high risk of dependency. Intramuscular anxiolytics injection which is Midazolam. However. It is important for us to treat it right now because it might affect his functioning if we do not treat it. I would like to prescribe it only for a short-term. Anti-depressant drugs which is Fluoxetine (SSRI). . I would like to prescribe this drug because the patient also complaint of depression symptoms. This will help the patient to calm down. less effects of hyperprolactinaemia. I chose this non-benzodiazepine hypnotic is because it has less hangover effect. and no food restriction like Tri-Cyclic Anti-depressants (TCA) Hypnotics which is Zolpidem. my patient needs admission to the ward because he might continue harming other people especially his work’s colleagues as he could not control the auditory hallucination that he had. I would like to start the patient with. relatively safe if overdose. I would like to start the patient with oral drugs which are. Intramuscular anti-psychotics injection which is Haloperidol. It also can treat both positive and negative psychotic symptoms.As far as I am concern. For the biological treatment. and less effect of cognitive impairment.
This is important for him because it will help him how to handle his problems appropriately and therefore will help him to avoid relapse. Other than that. This is important especially for the patient so that he will know the early symptoms of his illness. it is important for the patient to find another way to avoid this stressor. This will make them more understand and give full support to the patient. I also would like to put the patient for regular follow-up so that I can give supportive psychotherapy and reinforce on the good aspect especially the importance of compliance to medication. Moreover. the importance of comply to medications.For the psychosocial treatment. it is also important for us to tell the patient about the importance of identifying the stressor. they need to be told about the patient’s illness. It is because from the history. the obvious stressor is because of his works and his relationship with his employee. the family members also need to know the importance of patient’s compliance with his medications. For the family members especially his wife. I would like to give psycho-education for the patient and his family. Besides that. This also will help the patient to strengthen his insight. Therefore. . the precipitating factor is poor compliance to medications. By identifying the early symptoms. I would like to give coping-skill therapy for my patient. Like in this case. the patient will learn how to cope with it.
especially about his compliance to the medications. in between the episodes. The onset of his illness also is a late onset where he had this illness when he is 42 years old. His wife is also a nurse who knows that it is importance for a patient to take the medications accordingly. however for me. from the view of un-modifiable prognostic factors. Other than that. From the history. I am sure that my patient will have good support from his wife. and low mood. The reasons I said this is because my patient can function very well. Maybe it might cause some problems especially in the financial aspect. . in my opinion. either socially or occupationally. I would like to discuss about the precipitating factors that the patient had. His family history also did not have any psychiatric illness. Therefore. in psychological aspect of management. Therefore. From here. He also claimed that now he can identify the early symptoms of his illness such as stress. In the other hand.Discussion In this discussion. his prognosis is good. we can see that the medications did a good job as it treated the symptoms very well. it was very poor. his health is more important because we know that money can not buy healthy. the prognosis of my patient is good. Why I said so? It is because it is very obvious that the patient do not have enough education about his illness and the importance of medications. I would like to suggest to my patient about changing his jobs. even the stressor in this admission is due to poor compliance to his medications. In this case. This shows that the patient already has good insight but we need to help him to gain more and strengthen it. the patient also has a good support from his wife and his siblings. however I think that can be treated by giving adequate education about his illness and the importance of compliance to the medications. Therefore. During the interview. having auditory hallucinations. the patient already realized that it was a mistake to stop taking his medications. and the importance of compliance to the medications. we know that patient felt that he had become healthy and do not need the medications anymore. the perpetuating factor in this case is due to poor compliance to the medications. From the history. Furthermore. from the history. it is obvious that the stressor is because of his works. what I want to stress here is that psycho-education is as important as medications for my patient to have because this will help him to know more and realize about his illness. Therefore. However.
Diagnostic Criteria from DSM-IV. American Psychiatric Association. Kaplan & Sadock’s pocket handbook of clinical psychiatry. . McGraw-Hill. 3rd Edition.References • • • • Oxford psychiatric textbook. 3rd Edition. First aid of psychiatry clerkship.
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