CASE WRITE UP 2

PSYCHIATRY
YEAR 4
_____________________________________________

NAME : MUHAMMAD AMIRUL HAFIZ BIN

KHAIRUDIN

ID : 0120130100122

GROUP : ROTATION 5
LECTURES : DR HAITAM
: DR TIN
: PROF ZUL
DATE : 7TH JULY 2017
IDENTIFICATION DATA :

Name : Mr. R

Age : 45-year-old

Sex : Male

Occupation : Storekeeper

Race : Malaysia

Religion : Islam

Marital status : Married

Address : Klang, Selangor

Date of admission : 18th JUNE 2017

Date of clerking : 28th JUNE 2017

Ward : Psychiatry Ward, Hospital Tengku Ampuan Rahimah

Informant : Patient himself

CHIEF COMPLAINT :

Auditory hallucination 2 months

HISTORY OF PRESENTING ILLNESS :

A 45-year-old, married, Malaysia gentleman working as a storekeeper from Klang with no

known medical illness was brought to the hospital by his brother-in-law after the patient
reported that he used to listen to voices when he was conscious. He had been hearing those
voices for the past 2 months. He said those voices were not familiar to him and those voices
were directly speaking to him. the content of the voices usually was commanding which the
voices command him to lying down in the middle of busy road. There was no variation in
time in hearing those voices that means he heard those voices continuously until he managed
to sleep. Due to this, he has been caught and being brought to the hospital

Otherwise, he denied see something that others cannot see, smelling something strange that
others cannot smell, tasting something strange that others cannot taste, strange touching
sensation that others cannot feel.

He also reported had feeling someone was going to harm him if he went outside his house.

Otherwise, he denied television or radio are talking about him, his action or feeling being
controlled by others, others know what he is thinking without him telling them, thought being
inserted into or taken away from his mind.

6 months ago, he have feeling of worthless and hopeless where he claimed that he feels like
there is no meaning of living this life anymore. This occur after his mother recently pass
away due to natural causes.

In addition to that, currently, he believed that he is one of kind and have a special abilities to
control the world. He also stated that he is have too many ideas in his mind to plan for his
future.

He also experienced reduced need in sleeping since he will able to sleep at 4.00 am and wake
up at 7 am, when normally he will sleep at 10.00 pm and wake up at 6 am. There were
several days that he did not sleep at all. He claimed that he was energetic despite of the lack
of sleeping hours. Her sister did notice that he started being more talkative than before.

Because of this, his work effectiveness have been deteriorate. He unable to concentrate and
perform his job very well.

Otherwise, Mr. R did not experience any changes in his appetite or weight, and does currently
does not feel depressed, worthlessness or fatigue. . He did not has any feelings of nervousness,
palpitation, tremor, and hyperventilation or sweats suggestive of anxiety symptoms. He denied
of having suicidal thought. Patients also denied having history head trauma and usage of illegal
substance abuse such as cocaine, amphetamine or cannabis.
PAST PSYCHIATRY HISTORY

Mr. R has no psychiatric history before this. This is his first hospitalisation due to mental
illness. Currently he is under medication Risperidone and Lithium.

PAST MEDICAL AND SURGICAL HISTORY

Mr. R has no known medical illness such as thyroid disorder, cerebrovascular disease or
epilepsy. He also denies having diabetes mellitus or hypertension. No surgical intervention
was done previously.

FAMILY HISTORY

His mother has passed away 6 months ago whereas his father is still alive and healthy/ But
His father do have history of psychiatric illness however he unsure about the name of the
illness. Both of his parents is still alive and healthy. He is the first child among the four
siblings. He claimed that he has good relationship with the siblings.

PERSONAL HISTORY

Prenatal / Perinatal events

According to his knowledge, he was delivered normally with no complications. Otherwise, he

was unsure about her mothers condition during the pregnancy.

Developmental history

He was unsure about this matter.

Childhood history

He denied having neurotic symptoms such as bed wetting, thumb sucking, nail biting or hair
plucking during his childhood.

School history

He studied at Sekolah Menengah Kebangsaan Meru until the age of 17. He told that he was
an average student in his class. He did not further studies due to financial problems and less
interest in pursuing secondary education since he did not enjoy studying. He described his
school time as uneventful since he never involved in violence, truancy or bullying. He had
few friends in school and had good relationship with them as well with the teachers.
Work history

He started working immediately after finishing his high school. Previously, he had multiple
jobs such as factory worker and construction worker. He said those jobs was tiring to him and
that was the reason he ended up working as a storekeeper since 10 years ago. He claimed that
he has no problem with the employer and fellow friends at his workplace

Marriage history

He married at the age of 29 whereas his wife was 24-year-old. It was a love marriage and
They are blessed with 3 children whom age is 16, 12, and 9-year-old respectively. He claimed
that he had no issues or problems neither with his wife or children.

SOCIAL HISTORY

Mr.R has been living in Malaysia since 2005. Currently he lives with his wife and their
children in a rented house at Klang. They have been living there for almost 3 years. Her wife,
Madam J works as a janitor at his workplace. Their incomes are sufficient enough to fulfil the
basic necessities. He claimed that he has no financial issues.

DRUG AND SUBSTANCES HISTORY

He did not take any medications since he was healthy before this,. He is a smoker claiming he
smokes 5 sticks per day since the age of 19-year-old. Otherwise, he denied abusing alcohol or
illicit substances such as cannabis or amphetamine.

PREMORBID PERSONALITY

Mr. R described himself as a shy person before the illness. He said that he has a small circle
of friends at his workplace. He enjoyed watching television at home and spending time with
his family.
MENTAL STATE EXAMINATION

A Malay gentleman in late 40s who appears appropriate

to his age with moderate built.
His overall appearance is neat and clean, however his hair
appeared to be slightly messy and uncombed.
No abnormal movements, no signs of anxiety such as
General appearance sweating of hands and restlessnes.
He was cooperative throughout the session and has good
eye to eye contact.
Rapport was easily established.

He converses in Bahasa Malaysia fluently

He appears to be talkative and his speech are pressured
Speech speech.
He appear to have flight of ideas where he start talking
on one subject then switch to another subject with little
connection between them
His rate is rapid otherwise the volume and tone of
speech is normal.
His answers to some questions are irrelevant and
sometimes incoherent.

Mood His mood is euphoria at that moment since he

mentioned that he is feeling excessively happy.

Affect He has inappropriate affect but congruent to his mood.

He sometimes appears to be smiling when talking serious
matters.
 Thought form

The flow of thought is slightly slow since he took quite

some time, like searching for words before answering the
question.
There is circumstantiality, in which Mr. R would talk
unnecessary things which often preoccupied with religious
matters before reaching the answer of the question asked.
Otherwise, there is no clang association, tangentiality,
looseness of association, word salad or thought block.
Thought disorder

Thought content

Currently,Mr. R does not have persecutory delusion,

thought withdrawal or insertion but he did have a
grandiosity. Otherwise, no suicidal, homicidal or
depressive thoughts.

Perceptual disorder Currently, he denied having any form of hallucinations

during the clerking.
 Orientation

He was well-oriented to time, place and person.

Memory
Cognitive function test
His memory test on immediate, recent and remote are
intact which he was able to recall 3 objects (tree,cat,car),
able to tell what he takes during breakfast and able to tell
the name of his school.
He able to recall the object after 5 minutues.

Attention and concentration

Patient was not able to complete the serial subtraction test

of 100-7

General Knowledge or Intellectual

Mr. Rs intelligence appeared to be average since he can

tell the name of the current Prime Minister of Malaysia

Abstract and concrete thinking

He was able to tell the similarities between apple and

orange.

Judgment

He has good judgment in which he tells that he would call

firefight if his house is on fire.

Mr. R has good insight.

He believe that he is mentally ill.
He also does aware that all the symptoms experienced are
part of the illness process.

Insight
SUMMARY

A 45-year-old, gentleman married working as a storekeeper with family history of psychiatric

illness was brought to the hospital after claim to have auditory hallucination which is 2nd type
and commanding in nature which told him to lying down in the middle of busy road for the
pass 2 months. He also reported had feeling someone was going to harm him if he went
outside his house.

He have feeling of worthless and hopeless where he claimed that he feels like there is no
meaning of living this life anymore after his mother passed away. Currently, he have
grandiose delusion and required less need of sleep. He also claimed that he was energetic. He
was being more talkative than his usual self. These symptoms have make deteriorate his work
life.

On mental state examination, patient appears to be unkempt wearing the hospital attire with
uncombed and messy hair. He is easily distracted and irritated by the noise from surrounding.
He speaks in fast rate , and have flight of ideas. His mood currently is euphoric which is and
having inappropriate affect. The flow of thought is slightly slow and he also has
circumstantiality. Mr. R also experiences grandiose delusion. Currrently, He denied
experiencing any form of hallucination. On cognitive function test, Mr. R everything was
normal and he has a good insight
DIAGNOSIS

Provisional diagnosis

Bipolar Mood Disorder 1 in manic phase with psychosis

- Auditory hallucination
- Persecutory delusion
- Grandiosity
- Reduced need for sleep
- Energetic
- Talkactive
- Symptoms affect occupational functioning
- No medical illness or history of illicit drugs
- Unkempt appearance
- Euphoric mood
Differential diagnosis

Diagnosis Supporting points Against points

Psychotic symptoms Present of mood

(auditory hallucination, symptoms
Schizophreniform
Persecutory delusion)
within 2 months

Psychotic Symptoms Presence of manic

Depression symptoms symptoms
Schizoaffective disorder

Substance induced mood disorder Mood and No history of

with manic features psychotic substance abuse
symptoms

Mood and No history of

psychotic general medical
Mood disorder due to a general
symptoms illness
medical condition with manic
features
MANAGEMENT

Patient setting

- In patient because he could cause any harm to others

Investigation

I. Biological :
Aim : To rule out substance abuse or medical illness that may induce the symptoms as
well as to monitor the side effects of the medications

(i) Full blood count To rule out leukocytosis which can indicates infection
(ii) Blood Urea and Serum Electrolyes (BUSE) to assess kidney function before
administering drug
(iii) Urine for drug testing : To rule out substance abuse that induces the
symptoms
(iv) Thyroid function test : To rule out thyroid disorder
(v) Random blood sugar : To rule out hypoglycaemia and a part of assessment of
patient general condition to monitor side effects of medications given
(vi) Liver function test
(vii) Lipid profile : To monitor cholesterol level because atypical psychotic
medication can cause metabolic syndrome
(viii) ECG : Since this patients age is more than 45-year-old, thus ECG should be
done to monitor his heart condition before initiating the medications

Other investigations are unnecessary to be done in this case. CT scan or MRI is done
only when there is presence of suggested neurological abnormality or persistent
cognitive impairment. CXR can be done only when there is suggestive comorbid
respiratory or cardiovascular condition.

II. Psychosocial :
- Obtain collaborative history from family
- Consult with patients employer and colleague with his consent
Treatment

I. Biological :
Atypical antipsychotic should be given such as Risperidone because it is cheap and
yet effective. However, we need to monitor patients lipid profile as one of the
common side effect for atypical antipsychotic is Metabolic Syndrome.

Next, we give the patient mood stabilizer such as Lithium or sodium valproate

II. Psychological :
(i) Psychoeducation :
This involves both patient and his family members.
They should be provided with accurate information and details regarding
the nature of Mr. Rs condition which is Bipolar 1 disorder.
Educate on the importance and compliance of taking medication.
Reassure them that this condition can be controlled with compliance to
medications and inform about possible side effects.
Besides, educate them about the warning signs of this illness and prognosis
of it.
And also the importance of follow up and where to seek help

(ii) Psychotherapy :
- Cognitive Behavioural Therapy :
Provides education and support and helps a person comes to terms with the
illness.
This therapy also teaches patient the skills for coping with psychosocial
stressors and associated problems.
Besides, this psychotherapy facilitate compliance, monitor occurrence and
severity of the symptoms.

Supportive psychotherapy :
This is done to comfort and to reassure the patient and his family regarding the
patient illness. This is done by :
Listening to their problems
Let them ventilating their thought
Reassurance
Suggestion
Strenghtening the patients defence mechanism
III. Social :
(i) Counselling :
One of the important aspect for this patient. In this counseling, patient will be
given a lesson on the anger management as well as problem-solving skill

(ii) Occupational therapy :

Assess patients ability to work once patient is stable to ensure whether patient
requires supported employment after being discharge.

PROGNOSIS

Bipolar disorder is a chronic recurring illness. A typical patient has an average of 8 - 10

episodes over their lifetime. Prognosis of patients with bipolar I is worse compared to
patients with a major depression. Within the first two years after the initial episode, 40-50%
of patients experience another manic attack. Often, the cycling between depression and mania
accelerates with increasing age. The prognostic factors as listed below acts as a guidance to
assess the patients prognosis. For Mr. R, his prognosis for 3-month and 5-year are expected
to be guarded since patient has been experiencing long duration of manic episodes, having
psychotic features and due to his male sex. His illness also seems to be affecting his
occupational and social functioning. Besides, if his occupation is significantly affected by the
illness or due to his old age (since he is already in the late 40s), he might face financial crises
that lead to difficulty in continuing medical therapy for his illness. Therefore, this could
contribute to a bad prognosis in his later life.

Good prognostic factors Bad prognostic factors

Late onset Young onset

Good social support Poor social support
Married Impairment of occupational functioning
Shorter duration of manic phases Psychotic features
No psychotic symptoms Depressive features between periods of
Few medical problems mania and depression
Male sex
Family history of psychiatric illness
Single, divorcd or widowed

In this case, my patients 3 months prognosis is good as he has good insight on his condition.
His 5 years prognosis should be good too as he does have good family support and if he
compliance to medication.
DISCUSSION

Bipolar disorder is also known as bipolar affective disorder, or manic-depressive illness

(MDI). This illness is characterised by marked mood swings between mania (mood elevation)
and bipolar depression that cause significant personal distress or social dysfunction. There are
several aetiologies that could lead to development of this illness and amongst them are through
biological factors such as monoamine hypothesis that postulated norepinephrine and serotonin
are most implicated in the pathophysiology of mood disorders. Genetic factors also play an
important role in development of this illness. Apart from that, life events and environmental
stress as well as personality factors (histrionic and borderline) are the examples of psychosocial
factors for this illness. Based on the history given by Mr. R and clarification from the nurse,
the aetiological factors such as the genetic factors as well as the life event and stressful
environment could not be assessed properly in this patient. Therefore, collaborative history
should be obtained from the family members to determine the possible stressors or precipitating
factors for this patient.

There are four basic types of bipolar disorder. All of them involve clear changes in
mood, energy, and activity levels. These moods range from periods of extremely up, elated,
and energized behavior (manic episodes) to very sad, down, or hopeless periods (depressive
episodes). Less severe manic periods are known as hypomanic episodes. The four types are
Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder and Other Specified and
Unspecified Bipolar and Related Disorders. Mr. R. These 4 different types of bipolar disorder
is differentiated through the symptoms presented as described in DSM-V criteria. Based on the
history obtained from Mr. R, it is known that he fulfilled the Criteria A,B,C and D of manic
episode according to DSM-V which are elevated mood for more than 1 week (Criteria A), has
at least 3 symptoms listed in Criteria B which are grandiosity, reduced need for sleep, talkative
than usual and also distractibility. Mr. R is also noted to have impairment in social and
occupational functioning (Criteria C) and all of these symptoms hes facing is not attributable
to substances use or secondary to medical illness as mentioned in Criteria D. Therefore, he is
diagnosed to have Bipolar 1 Disorder, in spite of absent of depressive symptoms since the most
distinguishing, defining element of Bipolar I is at least one truly manic episode. A patient may
display psychotic symptoms such as delusions of grandeur or hallucinations as in Mr. R.

Proper diagnosis and treatment help people with bipolar disorder leads healthy and productive
live. The treatment of bipolar disorder is directly related to the phase of the episode (depression
or mania) and the severity of that phase, and it may involve a combination of psychotherapy
and medication since it is the most effective way to treat this illness. The medications such as
mood stabilizing medications as being prescribed in this patient which is Epilim (sodium
valproate) can greatly reduce the frequency and severity of Bipolar 1 Disorder episodes,
whereas the antipsychotic given can greatly control the psychotic symptoms faced by Mr. R.
Besides, the benzodiazepine given is useful to treat his sleeping problems. Other than that,
psychoeducation and psychotherapy plays an important role as psychological treatment. They
are helpful in such a way to decrease relapse rates, improve quality of life, and/or increase
functioning, or more favourable symptom improvement. This non-pharmacological therapy
also works at its best by providing support, education, and guidance to people with bipolar
disorder and their families
Psychodynamic Formulation

Predisposing factors : Family history. He father do have psychiatric illness.

Precipating factors : The mood symptoms appear after his mother passed away

Perpetuating factors : There is no perpetuating factor.

REFERENCES

1. Geddes, John et al. Psychiatry. 1st ed. Oxford: Oxford University Press, 2012. Print.
2. Stead, Latha G, Matthew S Kaufman, and Jason Yanofski. First Aid For The
Psychiatry Clerkship. 1st ed. Print.
3. "Bipolar Disorder". University of Maryland Medical Center. N.p., 2016. Web. 26
Nov. 2016. "
4. "Clinical Review: Bipolar Affective Disorder | Gponline". Gponline.com. N.p., 2016.
Web. 29 Nov. 2016.