You are on page 1of 21

Introduction

Name:Haffizudin Bin Rashid


Age: 23 years old
Race: Malay
Sex:Male
Marital Status: Single
Occupation: Unemployed
Informants: Brother, patient and case file
Rapport was established during the
second interview

Chief Complaint
Patient was brought to hospital for
aggressive behavior and assault
History:
- Patient was brought in by police accompanied by
his brother.
- His brother claimed patient became aggressive at
around 9pm today and he got punched over his
face and chest because his brother damaged the
door.
- Patient had became aggressive since 1 month ago
and his brother noted he has been smelling gum in
his room.
- His brother say patient has been sniffing gum for 2
years on and off, however for the past 3 months
patient has been sniffing more frequent

- Patient gets money from his sibling.


- When questioned about his behavior, patient
say he dont know why he behave abnormally
and doesnt remember any incidence.
- When asked about the reason he sniffs glue,
patient said he dont know and denies any
stressors which causes him to start sniffing
glue.
- Denies learning it from friend
- Denies any stressor that led him to sniffing glue
- No history of trauma, denies smoking or
drinking.
- Patient denied any visual, auditory
hallucination, no fever, no URTI, no UTI.

On second interview with the patient and brother:


- Patients brother claimed about 3 months ago after
Raya, patient has more money with him to buy glue.
- His brother unsure what the stressor is.
- When he packed patient room last week, he noticed
patient has damaged everything in the room and he
has found more than 10 tins of gum in the room.
- Noticed patient is bringing 2 tins of gum in his
pocket with him
- Patient was previously well when he did not sniff
glue, listen to order, never aggressive, no abnormal
behavior noted.
- Recently, patient is more aggressive and dance in
front of the house, when asked patient why, patient
claimed he dont know.
- His brother also say patient is unable to recognize
his family member.

On third interview with the patient :


- Patient claimed he was brought in by his brother
for treatment.
- Denied all the allegation claimed by his brother
- Denied hearing abnormal voice or seeing
abnormal vision
- Denied any delusion
- Admitted to glue sniffing for past 2 months of 1
small tin per day but later said he took 3 to 4
times per month then told up to 10 tin last week.
- Last glue sniffing yesterday
- Denied other substance abuse
- No family member or friends with substance
abuse habit
- Patient say he wants to stop glue sniffing.

On fourth interview with the patient :


- Patient feeling fine and claims he feel
healthier compared to before
admission
- He does not have the urge to sniff
glue anymore.
- Denies other substance intake

Past Psychiatric Illness


No history of any past psychiatric
illness.

Past Medical and Surgical


History

No history of any medical illness or


any surgery done.

Family History
Father passed away due to complication
of diabetes mellitus ; mother passed
away due to breast cancer .
When asked how patient feel about the
passing of his parents, he was dysthymic
and he denies any suicidal thoughts or
feelings of worthlessness or hopelessness
He lived with his brother and their
relationship is good.

Personal History
Date of Birth: 17th August 1993
- Claims to have been born and raised in
Pahang for 6 years before family moved to
Kedah when his father was transferred.
- No abnormality during birth and no
childhood health problem
Education: Until Form 1 (incomplete
education)
Patient had poor performance in school
Marital Status: Single
Occupation: Previously was a security guard
- Has good relationship with employer and his
colleague

Social relationships:
- Good relationship with his friends
and family
Hobbies and Interests:
- Singing
- Reciting poetry
- Reading newspaper
Pre-Morbid Personality
- Patient was previously well when he
did not sniff glue, listen to order, never
aggressive, no abnormal behavior
noted.

Current circumstances:
- Patient is being cared for by his
brother
- Patient claims that once he can stop
his addiction sniffing, he wants to
return working.
- He has no significant other to care
for nor any financial responsibilities

Mental State Examination

Appearance:
Normal body build and height
Well kempt in hospital attire
Good hygiene

Mood:
- Mood congruent and euthymic

Affect: Appropriate
Speech:
Normal rate and normal quantity
Spontaneous
No neologism or word salad detected
Normal reaction time

Thought
Answered spontaneously and able to
elaborate the answer
Goal directed
Possession:
- There was no thought alienation,
withdrawal, insertion or broadcast
- No obsession or pre-occupation

Content:
Answered what was being asked
No preoccupation
Perception:
Patient has no problems with
perception
- He denies hearing any voices talking
to him, about him or comment on his
actions.
- He denies having any visual
hallucinations

Cognition
Orientation:
- Patient is orientated to time, place and
person
Memory:
- Immediate, short and long-term memories
are intact
Unable to assess attention and concentration
as he is difficult to interrupt or persuade
Unable to assess visuo-spatial organization,
calculation, abstraction or executive
functioning
Unable to assess intelligence

Insight:
- During first interview, patient has very
poor insight (may be due to psychosis)
- Insight improved on second ,third and
fourth interview
- On third interview, patient is aware of
his problem, understands that the cause
is due to his returning habit of
substance abuse, and understands the
impact it has to his life and his
surroundings. He even says he will try
to stop sniffing glue and break free from
addiction

Physical Examination
Inspection:
- Alert and conscious
- No attachments to his limbs such as
cannula, IV drips, etc
Vital sign:
BP : 110/72
PR : 81
Temperature: 36.9
Sp02: 99%