FACULTY OF MEDICINE AND HEALTH SCIENCES UNIVERSITY PUTRA MALAYSIA

3rd CASE WRITE-UP

HAMZAH BIN NAJID 123149 4th YEAR MEDICAL STUDENT PSYCHIATRIC POSTING

SUPERVISOR: ASSOC. PROF. DR. BRIAN HO

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, accompanied by his wife and employee, due to aggressive behavior on the day of admission. History of Presenting Illness My patient is Mr. A, who was a known case of mental illness since 2 years ago, was admitted for the second time in HKL psychiatric ward, and currently on T. Haloperidol and T. Lorazepam, and had been followed-up at HKL psychiatric clinic. He was previously well until 2 days prior to admission where he mentioned that he was very stressed because of heavy workload. Because of the stress, he started to hear voices which were a womans voice, who always whispered to him to relax and be patient. He heard the voices during day time. He claimed that he tried to avoid hearing the voices by closing his ears, but it failed. He also mentioned that when he heard the voices, there was no one around him. On the day of admission, he went to work as usual. He claimed that on that day, he had a lot of works to be finished. But he mentioned that he just did his work as usual because he afraid he : : : : : : : : : : Mr. A 44 years old Married with 3 children Male Pantai Dalam Accountant clerk Malay Malay 18th July 2007 19th July 2007

might make mistake if he do it faster. Especially because of his work is arranging clients accounts. Unfortunately, his manager persistently pushed and pressured him to work faster but he refused because he afraid making mistake. He claimed that he need break for a while and could not sit the whole day. However, his employee keep pushed and pressured him. Then, about 3 oclock in the evening, while his employee asking him about works, suddenly he could not control his temper and throw his monitors computer towards his employee. Fortunately, his manager managed to avoid it and no injury occurs. He also damaged his computer altogether. According to him, just before the incident, he heard the same voices which asked him to crush down the computer. He did it not only because of the voices, but it also because of his temper to his employee. He denied doing any other harm to his employee. Then his manager immediately called his wife and asks her to come to the office. The manager also asked the other workers to calm him down. After he had calm down, he was brought to the hospital by his wife and employee. According to the patient, he stopped taking his medication since two months ago because he felt he already well and healthy. He also did not go for follow-up because he was too busy with his works. Furthermore, he also experienced low mood in the past two days before admission. He claimed that it only because of his works, and there was no other stressor. He denied having financial or marital problems. He also claimed that he had difficulty in sleeping where he mentioned that in the past two days before admission, he only could slept at 1 or 2 oclock in the morning, whereas he usually sleep at 11pm. He also claimed that he woke up early, about 4.30 am, whereas he usually woke up at 8. He also complained of lethargic where he thought it was because of not enough sleep. He also claimed that in the past two days prior to admission, he had loss his appetite and his weight, which was 3 kg in two days. He mentioned that during that time, he only took fruits during his lunch and dinner. He also claimed that he had loss his interest on his hobby which is playing football. He claimed that usually after work, he will play football with his friends. However, he denied feeling guilty or worthlessness, loss of concentration, or suicidal ideation. He also denied having any manic or anxiety symptoms. Mr. A also denied having any other hallucinations such as thought echo or discussing about third person. He also denied having any delusion of control, delusional preference or thought alienation.

Regarding his work during before being admitted, he claimed that he still can go to work like usual even in stressed condition. About his relationship with his wife and children before being admitted, he claimed that it was good and they were close to each other. During the interview, he kept asking for letter to allow the release of his EPF funds. He claimed that after being discharged, he wanted to stop working his current jobs, and started his own mechanics workshop. Mr. A denied taking any other drugs, substances or alcohol. 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. The admission was similar with this current admission. He mentioned that in the 1st admission, he also became stressed because of works and heard voices for three days before being admitted. He had been warded for one week and the symptoms were resolved shortly after treatment. 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. However, he unable to recall the medications that he had at that time. There was no history of electro-convulsive therapy or depot injection. Past Medical / Surgical History He had no chronic medical illness such as diabetes mellitus, asthma, hypertension or heart diseases. He never underwent for any surgery before. Family History

There was no history of psychiatric illness running in this family. His father had passed away due to motor vehicle accident when he was a baby. His mother passed away when he was 9

years old due to unknown causes. Both of his parents did not have any chronic medical illness. After that, his uncle was the one who take care of him and his other siblings. His siblings are still alive and all of them were healthy. Regarding his relationship with parents and siblings, he claimed that it was good, except with his father as he could not even remember him. He claimed that even until now, he and his siblings still support each other, and will help if anyone of them is in trouble. Past Personal History Prenatal History According to him, he was delivered normally during birth and there was no birth complication. Early Childhood (through age 3) He was breastfed until the age of 2. His development milestones were normal. Middle childhood (ages 3 to 11) He mentioned that he went to primary school just like any other child. He loved to play football and also others outdoor activity. He also likes to read story books. His academic level was average. He claimed that his mother passed away when he was in standard 3. However, he denied having any persistent depression symptoms. About his social relationship, he claimed that he had good relationships with other kids at his age. He had many friends at school and also at home. Later childhood (from pre puberty through adolescence) He went to secondary school until form 5. He claimed that he was active in sports and cocurriculums. His academic results were average. After form 5, he stopped studying and started working as a mechanic at his friends father workshop. He claimed that he had good relationships with girls and had many friends. He had no discipline problems. He also denied involving in any gangsterism. He also denied that he was a hot-tempered person or mood labile person. Adulthood He started working at the age of 18 as a mechanic. After that, he kept his jobs until at the age of 25, he changed his job as a security guard at a bank. After working as a security guard for 15 years, he had been offered to be an accountant clerk by his employee and he kept his job until now. His

salary was about RM1300 and he claimed that it is enough to support his family. He did not have any serious financial problems. However, he claimed that since two and a half year ago, he was not in a good term with his employee. He claimed that it was because his employee always gives him extra works. Regarding his social relationship, he had a lot of friends and always socializing with them especially at the evening where he goes to play football with them. He married at the age of 30 and now he has 3 children. He denied having any sexual or marital problems. He claimed that he is average in following the religion. Current Social History Now, he lived in his single storey-terrace house at Pantai Dalam with his wife and 3 children. He works as an accountant clerk at a bank. His wife is a nurse at O&G unit in Klang Hospital and she goes for work by using public transport. He is a smoker since 25 years ago, who smoke about 3-4 cigars per day. He did not take alcohol or self-prescribed drugs. He also denied taking any illegal substances. There was no history of sexual promiscuity. Premorbid Personality He described himself as an average and responsible person. Currently he is happy staying with his family. About his works, 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 mentioned that every time he had a problem, he will try to be patient and think about another better solution. He seldomly shared his problems with the others even with his wife.

MENTAL STATE EXAMINATION General Appearances My patient is a middle aged Malay gentleman, with a middle built body, thin with dark brown skin, with height which is about 170 cm and weight is about 60 kg, who is wearing only hospitals pants and pair of slippers. His hair was straight, non-curly, and short, but not well comb. He was not well groomed. His hygiene status was fair and he was not smelly. On the interview, he came voluntarily after his name was being called. Rapport was easily built and he was co-operative towards the examiner. Eye contact was good. There was no abnormal involuntary could be seen. However, he seemed having low mood during the interview. There was no manic or anxiety symptoms. Speech He spoke Malay very well. His speed and amount of speech were normal. However, his speech was slow in volume and monotonous. Mood & Affect During the interview, my patient rated his mood with 3 out of 10. 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. His affect was restricted but appropriate. Perceptual Disturbances He denied having any hallucinations during the interview. He claimed that once he admitted to the ward and took medications, the voices will disappear.

Thinking Form His form of thinking was normal, understandable, and with meanings. There was no flight of ideas, preservation, or loosening of association. Flow During the interview, his flow of thinking was normal. There was no thought block, thought retardation, or preservation. Content He denied having any delusions, preoccupations, or overvalued ideas during the interview. Possession There was no thought insertion, thought withdrawal, or thought broadcasting. All of his thought during the interview was of his own. Cognition Orientation During the interview, he was orientated to time, place, and person. He knew that he was in HKL psychiatric ward at the 1st floor. He also knew the correct day and date of the interview. He also recognized and knew the name of the doctor who is in charge for him. Conclusion: His orientation was intact.

Attention & Concentration He was able to do the serial 7 test in 80 seconds without do any mistake. Conclusion: Memory For immediate memory, 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.

For recent memory, he could recall three objects (cloth-car-bread) after three minutes correctly. For remote memory, he could remember his phone number, identification card number, and his homes address very well. Conclusion: His memory was well intact.

Information & Intelligence Comprehension: He could understand my questions very well and answered it properly. current prime minister, and Parameswara who was the first person to find Malacca. Arithmetic: He could answer simple arithmetic problems without problem. how much will get for the balance? He answered RM 2.75 correctly) Vocabulary: Conclusion: His vocabulary in Malay was good. His information and intelligence was generally fair and concordance with his educational level. Abstract thinking Proverb test: He answered correctly all the proverbs given as below; 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; 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; Pilllow Blanket Cake Car Van Pen (The price of an egg is 45 cents. You have RM 5 note with you. You want to 5 eggs. So, General knowledge: He was able to name all the Malaysians prime ministers, the United States

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? Ill tell him either to stop smoking for that time or smoke outside. What will you do if you see a stamped postcard nearby the road? Ill take the postcard and put it into post-box. What will you do if you are being discharged today? Ill go and rest at home first. Tomorrow Ill meet my employee to ask for quitting the job. Conclusion: Insight My patient aware about his illness but he did not remember the diagnosis for it. He could identify his early symptoms which are stress and auditory hallucinations. He also knew that the stressor was all about his works. He already thought about quitting his current job and starts his own business. However, before this admission, 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, he will comply with his medications and will not miss his follow-up. Conclusion: His insight was good. His judgment was intact. His abstract thinking was intact.

Physical Examination

My patient is a middle-aged, middle built, thin Malay gentleman, with fair hydration and hygiene status. There were no signs of hyperthyroidism or hypothyroidism. The vital signs were; Temperature Pulse rate Respiratory rate Blood pressure : 37C : 72/minute : 18/minute : 114 / 74 mmHg

Examination of cardiovascular system, respiratory system, gastrointestinal system, central and peripheral nervous system was unremarkable. Provisional Diagnosis Brief Psycotic Disorder Points for: - Auditory hallucination for more than 1 day and less than 1 month - Disorganized behavious (aggressive behaviour) - 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: - The presence of mood symptoms Differential Diagnosis Major Depressive Disorder with Psychotic Features Points for: - Low mood - Sleep disturbances - Loss of appetite, loss of weight - Always feels lethargic - Loss of interest to do his hobby - Presence of auditory hallucinations (psychotic features) Point against: - Duration of the symptoms was less than 2 weeks

* For the provisional diagnosis, I made the diagnosis is because according to the patient complaint, he more concerned and always talked about the auditory hallucination rather than the mood symptoms. However, as far as I am concern, even the duration of the mood symptoms did not fulfill with the one in DSM-IV, it is important for us to take it into consideration because it might affect or change in the management. Investigations Biological Full Blood Count to look for any underlying medical condition such as anemia, infections, or platelet deficiency. Also to obtain baseline value before starting the treatment. 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, look at the history, and the management that had been done. Interview his family members especially his wife to clarify and confirm the history, to get more detailed history especially about his premorbid personality, the social and occupational function of patient in between the admissions, to identify any others precipitating factors and stressors, and also to assess the relationship between the patient and the family members. Interview his employee regarding his works, clarify the history, identify and confirm the precipitating factors, and assess the relationship between them.

Treatment

As far as I am concern, my patient needs admission to the ward because he might continue harming other people especially his works colleagues as he could not control the auditory hallucination that he had. 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. For the biological treatment, as the patient presented to the ward acutely, I would like to start the patient with; Intramuscular anti-psychotics injection which is Haloperidol. This will help the patient to calm down. I would like to monitor the side effects of these drug especially the extrapyramidal side effects such as acute dystonia, tardive akathisia, and parkinsonism. Intramuscular anxiolytics injection which is Midazolam. The reasons I chose this drug is because it can treat the agitation in very short duration. However, this drug is just to stabilize the patient because this drug has high risk of dependency. When the patient has stabilized, I would like to start the patient with oral drugs which are; Anti-psychotic which is Respiridone (atypical antipsychotic). The reasons I chose this drug is because it has less extra-pyramidal side effects, less effects of hyperprolactinaemia, and less effect of cognitive impairment. It also can treat both positive and negative psychotic symptoms. Anti-depressant drugs which is Fluoxetine (SSRI). I would like to prescribe this drug because the patient also complaint of depression symptoms. It is important for us to treat it right now because it might affect his functioning if we do not treat it. I chose SSRI because it has less side effects of cardiotoxicity, less anti-cholinergic side effects, relatively safe if overdose, and no food restriction like Tri-Cyclic Anti-depressants (TCA) Hypnotics which is Zolpidem. This will help the patients sleep problems. I would like to prescribe it only for a short-term. I chose this non-benzodiazepine hypnotic is because it has less hangover effect. However, I would like to tell the patient that only uses this drug when necessary.

For the psychosocial treatment, I would like to give psycho-education for the patient and his family. This is important especially for the patient so that he will know the early symptoms of his illness, the importance of comply to medications. This also will help the patient to strengthen his insight. By identifying the early symptoms, the patient will learn how to cope with it. Other than that, it is also important for us to tell the patient about the importance of identifying the stressor. Like in this case, the obvious stressor is because of his works and his relationship with his employee. Therefore, it is important for the patient to find another way to avoid this stressor. For the family members especially his wife, they need to be told about the patients illness. This will make them more understand and give full support to the patient. Besides that, the family members also need to know the importance of patients compliance with his medications. It is because from the history, the precipitating factor is poor compliance to medications. Moreover, I would like to give coping-skill therapy for my patient. This is important for him because it will help him how to handle his problems appropriately and therefore will help him to avoid relapse. 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.

Discussion In this discussion, I would like to discuss about the precipitating factors that the patient had. From the history, it is obvious that the stressor is because of his works. Therefore, in my opinion, I would like to suggest to my patient about changing his jobs. Maybe it might cause some problems especially in the financial aspect, however for me, his health is more important because we know that money can not buy healthy. Other than that, the perpetuating factor in this case is due to poor compliance to the medications. From the history, we know that patient felt that he had become healthy and do not need the medications anymore. From here, we can see that the medications did a good job as it treated the symptoms very well. However, in psychological aspect of management, it was very poor. 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. Therefore, 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, and the importance of compliance to the medications. In this case, the prognosis of my patient is good. The reasons I said this is because my patient can function very well, either socially or occupationally, 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 family history also did not have any psychiatric illness. Therefore, from the view of un-modifiable prognostic factors, his prognosis is good. In the other hand, from the history, even the stressor in this admission is due to poor compliance to his medications, however I think that can be treated by giving adequate education about his illness and the importance of compliance to the medications. During the interview, the patient already realized that it was a mistake to stop taking his medications. He also claimed that now he can identify the early symptoms of his illness such as stress, having auditory hallucinations, and low mood. This shows that the patient already has good insight but we need to help him to gain more and strengthen it. Furthermore, the patient also has a good support from his wife and his siblings. His wife is also a nurse who knows that it is importance for a patient to take the medications accordingly. Therefore, I am sure that my patient will have good support from his wife, especially about his compliance to the medications.

References Oxford psychiatric textbook. First aid of psychiatry clerkship, McGraw-Hill. Kaplan & Sadocks pocket handbook of clinical psychiatry, 3rd Edition. Diagnostic Criteria from DSM-IV, 3rd Edition, American Psychiatric Association.