UNVERSITI KUALA LUMPUR

ROYAL COLLEGE OF MEDICINE PERAK

PSYCHIATRY POSTING CASE WRITE UP
Mohd Afiq Aizuddin bin Sarun
57260211008
Group: 5B
Subgroup: B1

Chief Complaint
Mr 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 Illness

Patient 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 History

This 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 History

Mr 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 History
Both 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 History
According 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 History
Mr 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 History
Patient is currently single and never married before.
Sexual History
Since Mr H did not understood the question that was given to him, I was unable to obtain this
sexual history.
Social History
According to the patient, he never smoked and drink alcohol before.1

MENTAL STATE EXAMINATION

General Appearance
Mr 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 Behaviour
Mr 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.

Speech
Speech 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 & Affect

I 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 Content
Patients 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.

Perception
Mr 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.

Sensorium
Orientation
Mr 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 & Concentration
For 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.

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

Insight
Overall, 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 DIAGNOSIS
Relapse Schizophrenia
Mr 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 DIAGNOSIS
Delusional disorder
Schizophreniform
Acute psychotic disorder
Brain reactive disorder

MANAGEMENT
Hospitalization
Assess 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.
Pharmacotherapy
Antipsychotic 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 Flucanthixone
Psychotherapy
Psychoeducation 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.