CASE CONFERENCE

Personal Details
1. Name: MS 7. Marital status: Married
2. Age: 45 years old 8. Address: Bandar Kinrara, Puchong
3. Sex: Female 9. D.O.A: 2nd Nov
4. Race: Malay 10. D.O.C: 8th Nov
5. Religion: Muslim 11. Informant: Patient herself
6. Occupation: Currently 12. Language Spoken: English, Malay
unemployed 13. Reliability : Non Reliable
Chief Complaint
She was brought in by the police officers due to aggressive behavior
 HOPI
• She was brought in by the police on 2nd Nov 2016 at 5.30PM because she tried to
enter the Jalan Semarak Army Base Camp.
• She went into the camp to meet the colonel to settle her paper work document.
She was confronted by an army officer. When the army officer questioned her,
she got upset and she claimed that the officer acted unprofessionally towards her
making others look at her like she’s insane. Other people started to take pictures
of her and this made her angry.
HOPI
• She claims she’s in the royal family and was given a secret identity for
security reasons.
• A report was lodged to bring her to the hospital. She was caught by
the police as reported by the army at the camp.
• Upon arrival to the ED, she was sedated with IM Midazolam 5mg and
IM Haloperidol 5mg and hence unable to be interviewed. Family
members instead were interviewed.
HOPI
• The informant was her younger sister, she does not remember the
diagnosis but she was told to take the medications and follow up
subsequently.

• Since Oct 2016, they noticed that she started acting abnormally where
she was more talkative and was seen to be talking and laughing by
herself.
• She also believed that she was of high status.
 HOPI
• Her condition worsened in the past month and were she started to have
a spending spree. She spent around RM40k but unsure for what
reasons.
• She kept asking for money around RM1k to RM5k. She even threatened
those with a knife for money. If she had expensive thing, others cannot
have it too.
• She kept saying she has a husband in London and other children. She
claims that people were spying on her just to see her because she was
special.
HOPI
• Recently she also tried to search on the TV for her lost son which was claimed to
be kidnapped.
• She threatened her family members and she scratched her sister because she
thinks that they took her money.
• She also feels like her siblings want to harm her and her husband wants to
divorce her and take her money while her neighbours wants her husband. She
also confronted her neighbours about this and started shaking their grill. She has
no proof and she said she just felt it.
HOPI
• She has decreased need for sleep. She has been sleeping 3 to 4
hours but still feels energetic. When she is awake, she would start
cleaning the house and start cooking.
• Appetite is the same.
• Weight is the same.
• Classical day: Laundry, cleaning and other house chores.
• Able to support self: No, supported by husband.
HOPI
• Patient does not feel sad. She does not feel hopeless, worthless or
guilty about anything.
• She does hear anything abnormal.
• She did not think about taking her life, as she feel life is beautiful.
Timeline
In Sept 2016,
she had poor
relationship
with husband 2 weeks ago,
Diagnosed with and stopped started to have
mental illness taking aggressive
in 2001. medication behavior.

Had multiple Oct 2016, started Current

admission ever acting abnormally. Admission
since. Talking Irrevantly.
Grandiose Delusions.
 Past Psychiatric History
• Patient was diagnosed with Bipolar Disorder with mood symptoms at
Hospital Taiping in 2001. She was treated there till year 2006.
• From year 2006 till present, she has frequent admissions to HKL psychiatric
ward due to same diagnosis.
• Her last admission was in April 2017 and her admission was for 3 weeks.

Past Medical History & Surgical History:

• Nil
Medication History
• From her last admission
o T. Epilim 800mg BD
o T. Olanzapine 10mg BD
o IM Fluanxol 20mg monthly

Allergy History
• No known food or drug allergies
Family History Father Mother

57y/o Husband Patient

27y/o 14y/o

5 siblings. She is the eldest. Married with a 57 year old male. Has 4
children.
No family history of mental illness or similar illness except her eldest son
age 27 who is Autistic.
 Marital History
• Married at 21 years old
• Love marriage
• Non - consanguineous
• She is staying with her husband at Bandar Kirara, Puchong

Personal & Social History

• Highest education was diploma in business management
• Use to work as a clerk then stopped at the age of 21 to be a housewife
• Development was normal
• Doesn’t smoke, take alcohol or drugs
Premorbid Personality
• Patient is optimistic
• She claims to be sociable.
• She says she is close with her siblings.
• She likes to do act and sing.
• She can cope well with new surrounding and situation.
• She is a religious person.
• She is a born leader.
Summary
• Predisposing factor: Positive family history of mental illness
• Precipitating factor: Separated from her husband
• Perpetuating factor: Non-compliance to medications
• Protective factor: Social support from her family
MENTAL STATUS
EXAMINATION
General Appearance
• Personal Hygiene: Good
• Make up and dressing: Did not wear make up and wearing hospital
attire
• Hair: Long hair, tied up, messy
• Mannerism: Sitting comfortably.
• No self injury or self neglect.
Behavior and Psychomotor activity
• Attitude: Irritable and talkative
• Poor eye contact and good response to questions.
• Facial expressions appropriate to emotions.
• Normal gait and posture (No tremors, dyskinesia, dystonia visible)
• Speech
 Quantity, rate and volume were in increased (Pressured speech)
 Had clear pronunciation and was fluent.
 Language spoken: English and Malay language.

• Mood
 Patient feels good and is happy.

• Affect
 Elated and appropriate to thought and content of
speech.
Thought flow
• Rapid and increased in amount

Thought Form
• Flight of ideas
• Example : “ My mother is my soul. My soul mate is somewhere, waiting for
me”
• No loosening of association, incoherence, neologism and
perseverance
Thought content
• Grandiose delusion
• She believes she is of royalty and she has special powers.

• No suicidal ideation or homicidal thoughts.

• Phobias: None
• Obsessions: None
• Compulsions: None
Thought possession
• No thought insertion, withdrawal or thought block.
Perceptual disturbances
• Hallucinations: None
• Illusion : None
• Derealization: None
• Depersonalization : None
Cognitive Status
• Consciousness: Patient was alert and aware of surrounding.
• Orientation: She was orientated to time, place and person.
• Attention and concentration: She is able to count from 1 to 20, then
in reverse from 20 to 1.
• Abstract thinking: Able to explain meaning of a proverb and compare
an apple and an orange.
 Cognitive Status
• Intelligence: Able to add, subtract and multiply with simple digits.
• General Knowledge: Able to tell whom is the first and current Prime
Minister of Malaysia.
• Writing: Patient was able to write simple sentences.
Memory
• Registration : Able to repeat 5 words mentioned.
• Short term: Only able to recall all five words mentioned.
• Long term: Able to recall high school.
Judgement
• Personal : When asked if given RM 10K, she said she would buy a ship to
sail the seas.
• Social: When asked if she was a treat to society, she said no.
• Test: If patient was in a fire, she would try to escape.

• Hence, patient’s judgement is poor because would spend more money

unnecessarily.

Insight
• Poor, as patient does not feel she is in the psychiatry ward for help
but was forced by her younger sister. She does not feel she needs to
take medications.
Diagnosis
• Bipolar mood disorder (manic phase)

Differential Diagnosis
• Schizophrenia
• Schizoaffective disorder
Investigations Done
• Full Blood Count- Normal
• Thyroid Function Test – Normal (Free T4, TSH)
• Liver Function Test – Normal
• Lipid Profile – Low HDL levels
• Renal Profile: Normal
• Random Blood Glucose Level: Normal.
• Urine Pregnancy Test: Negative
• Urine Analysis: Increased Bilirubin, Urobilinogen, Ketone, Protein and
Leucocytes
Vital Signs
• BP: 120/80mmHg
• PR: 84bpm
• RR: 20bpm
• Temperature: 37.0°C
• Weight: 163cm
• Height: 60kg
• BMI: 22.6 (normal)
Treatment Plan
• Tablet Risperidone 1mg BD
• Tablet Sodium Valporate (Epilim) 200mg BD
• IM Midazolam 5mg stat
• IM Haloperidol 5mg stat
• Tablet Clozapine 1mg x 3/7
• Abscond & Assault Caution
• To try & ask Hospital Taiping if record is still available
• Biopsychosocial Model and Psychotherapy to patient and family.
Ward Progress
• Patient is compliant to medication but she says it makes her feel
drowsy after taking it
• She has been having good behavior throughout with no aggressive
behavior seen
Prognostic Features
• Good prognostic factor:
• Social support from siblings

• Bad Prognostic factor:

• Patient had multiple relapses due to non-compliance to medication.
• Poor relationship with husband
References
• Kaplan & Sadocks Synopsis Of Psychiatry 11th edition
THANK YOU 