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29 years old
Chinese
single
Present to outpatient clinic in hospital permai without
any company
On 21/4/2015
Working as a watch seller but is on unpaid leave for a
week
History was taken from patient itself
Presenting complaint
Difficulty in sleeping for past 2 weeks
Drug history
2010-Mirtazapine 15mg half tablets OD for a week
Feb 2015(KK)- diazepam 1mg PRN
March 2015(psychiatrist)- Mirtazapine 15mg half tablets
OD for 4 days, stop after feeling better
No known drug allergy
Family history
Father passed away at the age of 48 years old due to
heart failure
Mother is 68 years old, having diabetes, hypertension
and chronic kidney disease, on dialysis 3 times per
week
No siblings
Cousin is diagnosed depressive disorder
Personal History
Birth and childhood- vaginal delivery with no developmental problems.
He moved to stay with his uncle from 3-7 years old as his parents need
to work, he was happy and no history of abuse. His parents visit him
once a week.
Education- good relationship with friends and teacher in school.
Complete secondary level education
Employment- first job at the age of 18 years old(father passed away and
he became the main support in the family) as a watch seller until now.
Current salary RM2.5k
Psychosexual-have been in a relationship for 2 times, no history of
sexual assault.1st gf- separated due to financial instability. 2nd gfseparated at September due to long distance relationship and this upset
him. He is still hoping to get back together
Social History
December 2014- accompany mother for dialysis thrice a
week, no time for self
Poor relationship with colleagues,unable to fit in
No financial dept
No smoking
Forensic History
none
Premorbid History
Introvert
Friendly to friends
He is a budhist
Thoughts
No formal thought disorder. Preoccupation theme: his
health condition
Perception
patient denied any experience of hallucination
Cognitive function
appeared alert, orientated in time, place, person,
attention and concentration appeared intact, patient could
recall 3 objects
Insight
aware of his condition and ready to accept treatment