CASE PRESENTATION –

IYAN A/P SEE RAK

PATIENT IDENTIFICATION

• Name – Iyan A/P See Rak• Age – 52 • Sex – Female• Address – Kampung Kura, Sik, Kedah• Occupation – Unemployed • Marital status – Divorcee • Religion – Buddhist • Nationality – Malaysian

CHIEF COMPLAINT

• Patient was brought to hospital by her son on 14/09/15.

• She claimed that she did not want to stay at home because she was feeling very scared that she might see ghost.

• She also stated that she started to think too much and ended up performing continuous activities which she is unsure of.

HISTORY OF PRESENTING ILLNESS

• Patient claimed that her current condition started to develop a few months ago.

• Patient was always unable to sleep at night due to her fear of seeing ghost and is afraid to stay alone.

• Patient claimed that she tried to sleep with lights on but she could not sleep and ends up praying frequently at night.

• She feels tired and sleepy in day time due to lack of sleep.• Patient claimed that she felt unorganized and had a lot of

things in her mind, desire of doing many works at the same time but she could not recall the work that she did.

• She used to see her son’s picture for long time whenever she is feeling alone.

• Patient also claimed that her neighbour behind her house is trying to harm her and make her condition worse by giving her food.

• She admitted that she is not taking her medications regularly and only takes them whenever she have a heavy meal.

• Patient claimed that she has a good appetite and good energy.

• She does all the house chores by herself, walks to the nearby shop if she needs to buy something and takes care of herself.

• Currently, she denies any auditory or visual hallucinations.• Denies delusions. • Denies thought insertion, thought withdrawal, thought

broadcasting and thought block.• Denies any suicidal thought

PAST PSYCHIATRIC ILLNESS

• Patient had a history of Schizophrenia previously after the birth of her first child.

• Patient claimed that after her delivery, she heard voices talking and saying “I love you” to her for a few weeks and according to her it is a male voice.

• Patient could not stand the disturbance and went to hospital in Alor Setar to seek medical assistance.

• Then, she was under anti-psychotic medication (Risperidone) and follow up in psychiatric clinic.

• Patient claimed that her condition got better and no disturbance after taking the medication and she is compliant to the meds.

PAST MEDICAL AND SURGICAL HISTORY

• Patient had been admitted once at Hosp. Sultanah Baiyah for trying to commit suicide by drinking poison.

• Patient was unsure of the date or month and claimed that it was a few months ago.

• The reason for her act is she was feeling lonely and don’t want to live.

FAMILY HISTORY

• Patient’s parents divorced when she was young and both the parents remarried. Patient lives with her mother since then and her mother passed away after a few years.

• Patient have 3 biological siblings and 2 step-siblings• 1st child – brother, 55 y/o, married and works as a rubber

tapper. Lives at Sg. Petani• 2nd child – patient • 3rd child – sister, 48 y/o, married and works at Singapore• Patient claimed that there is no history of mental illness

in her family.

• Patient is married with one child but divorced her husband after getting the first child.

• Her husband is now married to another woman.

• Her son, Shunton, currently 28 y/o, working as a lorry driver and is engaged. According to her, he is going to get married soon.

PAST PERSONAL HISTORY• 1 – prenatal history – patient claimed her mother did not

tell her because she passed away when patient was young.

• 2 – childhood history – patient studied until form 6. She claimed that she likes to go to school and her relationship with the teachers and friends were good. She participates in school activities well. She also claimed that the teachers took care of her because she cries at school sometimes when the parents got divorced. She also stated that she had the scared feeling since small.

• 3 – menstrual history – patient attained menarche when she was 13 y/o. Her cycles were regular with 3-5 days of flow and she experiences dysmenorrhea

• 4 – Religious background – she is a Buddhist with strong faith and she prays regularly.

• 5 – Occupational history – she started working after form 6 in a Sony Company due to her unstable family condition. Patient is currently not working and she claimed that she prefers to stay at home and rest than to work.

• 6 – Marital history – she was married at the age of 20 and got divorced after getting her first child. She claimed that her husband was in relationship with another woman and she accepted it because according to her it is normal for male to be in other relationship. However, patient is not married to anyone else.

CURRENT SOCIAL SITUATION

• Currently, patient is staying alone at Kg.Kura, Sik, Kedah

• Patient is taking care of her living cost by herself as she is receiving BR1M from the government.

• She is satisfied with the income and able to manage herself.

PREMORBID PERSONALITY

• 1 – Character – my patient is a friendly and cheerful person as she was very cooperative and able to communicate without being irritable. She also prefers to be with many people because she claimed that staying alone brings fear in herself. She wants to be in a good relationship with everyone.

• 2 – Habits – she does not smoke, take drugs or consume alcohol. Her eating habits are regular and normal.

• 3 – Attitudes – she is pessimistic sometimes and feels that her neighbour is trying to harm her and make her condition worse by giving her food. Otherwise, she is cheerful and happy

• 4 – Relationship – she is a caring and loving mother as she is happy about her son’s engagement and she wants her son to get married soon and be happy. She also claimed that she wants to invite all her relatives and friends to share the happy moment. Her relationship with her siblings are good as well.

• 5 – Religion – she is a Buddhist and have a strong faith in her religion. She claimed that she prays regularly whenever she is feeling alone and scared.

• 6 – Mood – she is a very happy and cheerful person. She always sing songs in the ward. She also appears calm and relaxed with a stable mood.

• 7 – Hobbies/Interest – she does not have any hobby in particular but she occupies herself by doing house chores.

MENTAL STATUS EXAMINATION

• 1 – General appearance/Behaviour – patient was well kempt in hospital attire with good hygiene. Patient was calm, cooperative and communicative throughout the interview. Her eye contact was good.

• 2 – Speech – patient’s speech was coherent and relevant. The amount is slightly increased but the volume, speed and tone was normal.

• 3 – Mood/Affect – patient’s mood was euthymic and affect was appropriate.

• 4 – Perceptual disturbance – there is no active hallucinations, illusions and delusions.

• 5 – Thinking – no disorder of form because speech is coherent and relevant. Content is normal and acceptable. However, she is having flight of ideas, and increased productivity of speech. There is no possession of thought such as thought insertion, thought withdrawal, thought broadcasting and thought block

• 6 – Cognition :-I. Orientation – patient is well orientated to time, place and

person.II. Attention/Concentration – patient is only able to obtain 1/5 in

serial subtraction test which indicates poor attention and concentration.

III. Memory a- immediate – patient is only able to recall 3 digits forward and unable to recall any digits backward. b- recent – patient is able to recall what she ate for breakfast and what she had yesterday. c- remote – patient is able to recall her birth date.IV. Information/Intelligence – patient is able to tell all the Malaysian

Prime Minister name according to the order.

• 7 – Judgment – patient’s social and test judgment is good. However, her personal judgment is poor as she don’t have any future plans for herself.

• 8 – Insight – patient is aware of her illness and she knows that she needs medications to help her get better.

CASE FORMULATION

• Provisional diagnosis – Relapse Schizophrenia with the evidence of early stage signs of relapse such as :-

a- insomnia b- inability to concentrate c- restlessness d- excessive preoccupation of ideaswhich is of sudden onset and last for a few days. However, patient have not developed any psychotic symptoms yet.

• Differential diagnosis :-

1 – F25.0 – Schizoaffective disorder, manic type with evidence of delusion of persecution, overactivity, and impaired concentration. The episode is acute in onset and behaviour is grossly disturbed.2 – F30.0 Hypomania with evidence of persistent mild elevation of mood for several days, increased activity, talkativeness and decreased sleep. Concentration and attention are impaired leading to inability to settle down to work or to relaxation.3 – F51.0 Non organic insomnia with evidence of inability to sleep at night due to fear, sleep disturbance for several days. Presence of worried feeling and fear, preoccupied and unsatisfactory sleep at night which causes tired feeling and sleepiness in daytime. 4 – F60 – Paranoid personality disorder with evidence of distrustful and suspicious towards others. No other symptoms of schizophrenia are present.

INVESTIGATIONS

• Full blood count• Urine analysis for drug abuse/ drug overdose• Liver, thyroid and renal function test to rule

out concomitant illness• Brain imaging (CT/MRI) to rule out other

neurological disorders• EEG• Psychological evaluations

TREATMENT

• Admit the patient to the ward.• Medications – atypical antipsychotics should be given.

Ex Risperidone, Clozapine.• Behavioral chart to observe her condition• Psychoeducation should be given on how to manage

her fear.• Individual therapy to help her learn to cope with

situation and identify early warning signs of relapse• Family therapy to provide education on managing the

patient