UNVERSITI KUALA LUMPURROYAL COLLEGE OF MEDICINE PERAK

PSYCHIATRY POSTING CASE WRITE UP

Mohd Afiq Aizuddin bin Sarun57260211008Group: 5BSubgroup: B1

Chief ComplaintMr H is a single, unemployed 51 years old Malay gentleman from Ipoh, Perak was brought to Wad Kemasukan Lelaki of Hospital Bahagia Ulu Kinta by his brother four days before the clerking was made since the patient was talking and laughing to himself.

History of Presenting IllnessPatient is a known case of schizophrenia and as this is the patients 17th admission to Hospital Bahagia Ulu Kinta. Currently, patient mentioned of seeing few being which he later mentioned them as ghosts for the past two month. The ghost was described as wearing white piece of cloth with long black hair. Even after being admitted to the ward, he still can see them wandering within the complex. Further attempt to obtain other form of hallucination was uneventful as patient did not understood the question and he kept giving irrelevant answers. It was also difficult to find out whether the patient has any delusional symptoms due to the same problem. Apart from that, Mr H complained of having trouble sleeping since few months back, that now began to worsens in this one week period. He further mentioned of having trouble to initiate sleep that made him to sleep very late in the night and often awaken in the middle of night. Due of this problem, he often felt tired upon waking up the next day. However, his appetite was good and he never had any diminished interest in doing what he loves the most everyday, which is to watch television. Mr H also did not have any significant mood changes in these two month period.

Past Psychiatric HistoryThis is the patients 17th admission to Hospital Bahagia Ulu Kinta. His first admission dated back in November 1983 when he was 17 years old while his last admission was on August 2008. All of the 17 admissions were due to same illness that he was having which was schizophrenia.

Past Medical & Surgical HistoryMr H was currently taking medications to control his diabetes mellitus. Other than that information, the attempt to obtain the period of having this illness as well as obtaining any previous surgical history was uneventful.

Family HistoryBoth of his parents already passed away due to old age. Mr H is the third out of his 10 siblings. No other family members were noted to have any mental illness, including in families on his paternal and maternal side. Patient mentioned that he was having good relationship with all of his siblings, especially with his elder brother whom currently the patient is staying with.

Personal HistoryAccording to the patient, he was born through spontaneous vaginal delivery and has no trouble growing up as a child. He never had any serious medical condition during his childhood and have normal developmental milestones. Mr H completed his study up to SPM level and as the patient claimed, although his UPSR, SRP and SPM was not that good, he managed to pass all of them. The patient also claimed that he liked to participates in the activities organized by the school especially in sports such as football and running. He had no trouble getting along with his friends and teachers during his primary and secondary school.

Work HistoryMr H never had a job before and he stayed with his elder brother and sister-in-law. Currently, the brother supported him in terms of welfare.Marital HistoryPatient is currently single and never married before.Sexual HistorySince Mr H did not understood the question that was given to him, I was unable to obtain this sexual history.Social HistoryAccording to the patient, he never smoked and drink alcohol before.1

MENTAL STATE EXAMINATIONGeneral AppearanceMr H is a thin man, sitting with upright posture comfortably and also was conscious and alert during the interview. He was well dressed, wearing the hospital attire and as for the personal hygiene, patient was noted to be clean and tidy. He has good eye contact and appeared calm during the session. Furthermore, he was reactive to his surroundings, behaving very well during the interview and was willing to cooperate when he was asked to do so.

Overt BehaviourMr H does not appear to have nay abnormal gait. Upon shaking his hand, he has a firm grip and his palm is warm but not sweaty. For most of the session, Mr H did not showed any signs of any abnormal movement such as foot tapping nor nail biting. He also did not have any agitated movements and having any aimless, purposeless activity.

SpeechSpeech wise, patient was able to speak Malay fluently, use appropriate tone and spoke with a normal rate. His speech content however tends to be irrelevant most of the time and also having looseness of association. Mr H also displayed the features of tangentiality in his speech. For example, when he was asked about his job, he mentioned of going out to the cinemas with his friend in the old days. Otherwise, patient did not have any neologism, word salad nor echolalia in his speech.

Mood & AffectI was unable to assess his mood since he kept going irrational answers to most of my questions. His affect however appeared appropriate to the mood

Thought ContentPatients thought was assessed next. His thought was noted to be incoherent and irrelevant to the topic being discussed. Other than that, Mr H was unable to provide any information whether he has any delusional symptoms due to the problem stated before.

PerceptionMr H was noticed to have visual type of hallucination since he mentioned of seeing ghost wandering at his house and in this facility. Other than that, he denied having any other form of hallucination such as auditory, gustatory, tactile and olfactory.

SensoriumOrientationMr Ridzuan was only able to tell the time correctly upon questioned. He was also able to distinguish the medical students from the doctors in the ward as well as knew he was at the hospital.Attention & ConcentrationFor the immediate memory, patient was able to tell the five objects that he was told to remember. His recent memory was also good since he could tell what he ate for breakfast that morning. For the long term memory, he was able to remember his first admission to the hospital and some of his childhood events.All the other tests for concentration were not done since Mr H did not understood the command that was given to him.

JudgementAlthough the patient was presented with some imaginary situations, he still gave irrational answers, not related to the question.

InsightOverall, patients insight was good. He knew that he is having schizophrenia and felt that it was important to take the medication he was prescribed.

PROVISIONAL DIAGNOSISRelapse SchizophreniaMr H presented with the history of having delusional symptoms, hallucinations and he was having disorganized speech for the past two months. It met the criteria to diagnose this patient with schizophrenia according to the DSM IV criteria which requires all the symptoms to be present at least within one month period. Since this is not his first time being diagnose with this condition, it is likely due to the relapse of the condition, most probably due to default medication.

DIFFERENTIAL DIAGNOSISDelusional disorderSchizophreniformAcute psychotic disorderBrain reactive disorder

MANAGEMENTHospitalizationAssess whether patient is required to be hospitalized or not. If there is presence of threat to himself or others, it is most likely suitable to hospitalize this patient until the risk is gone. It is also wise to hospitalized patient with bizarre psychotic symptoms in order to get these symptoms controlled. Most probably, Mr H was sent here due to this reason.PharmacotherapyAntipsychotic drugs is most likely to be used in order to manage the psychotic symptoms. Atypical antipsychotics, such as Olanzapine and Risperidone is preferred compared to conventional antipsychotics since they have much lesser adverse effects. Consider to use Clozapine if patient doesnt respond well to the common drugs of atypical antipsychotics but be aware of the agranulocytosis, a potential lethal side effect of the Clozapine.Electroconvulsive therapy is preferred in case the patient did not respond well to the drugs, either the drugs did not achieve any significant improvement in patient or in case of patient unable to tolerate with the side effects of the antipsychotic medications.If the patient was not compliant to medications, we can start the patient with IM Depot such as Fluenzole or FlucanthixonePsychotherapyPsychoeducation is important in managing cases of schizophrenia. The patient as well as his family should be educated on the disease, such as when and how to diagnose the signs and symptoms of the disease, signs and symptoms of relapse, type of medications, the importance of medications and the adverse effects of each medications. It is also important to teach the patient how to cope with illness and people surround him. Patient also need to be taught to practice a healthy lifestyle through exercise and healthy diet.Since most of the patient of schizophrenia was unable to perform well in their daily life that could make them to have any occupation, patient should be provided with social skills training and occupational therapy sessions. With this, it is hopeful that the patient will able to find a job and able to support himself in the future.