Preliminary identification medical card was stolen along with her belongings and so she could not

come.
Name: Selmah binti abdul ghani

Age: 49 years old This is apparently the patient's third admission to HHT and it is due to
worsening of symptoms due to her poor compliance. It all started about a
Race/religion :malay lady
week ago as patient was noted to become increasingly irritable by her
marital status: widowed 9 years ago
sister whom she visits every 2 weeks or so for money. She would get
Occupation: works as a cleaner at multiple places ( JKN, temple, bank), angry very fast if the sister refused to give her money and refused to stay
lives by herself around kt town and does not have a fixed accomodation. with her saying that she has important work to be done in town. Patient
D.O.A : 8/11/2015 ( 10 days ago) regards herself as an important person and claims that she is a minister's
adopted daughter ( Dato Toh) and that he willed a huge company that
D.O.C: 16/11/2015 ( on the 8th day )
profits millions each month to her and appointed her as the manager ever
Source of info: Patient herself and her case files
since she was 15 years old. However, the company was taken over by her
Reliability: quite reliable husband when she got married. But even then she claims that she hold an

Chief complaint :
Patient was brought in by the police due to her persistently irritable mood
for more than a week which lead her to become a disturbance to the public
and aggressive behaviour on the day of admission.
HOPI:
Patient is a known case of mental illness for more than 20 years diagnosed
in HSNZ and was prescribed with epilim 600mg and risperidone 2mg and
was under follow up at HSNZ but defaulted her treatment since October
last year after her last admission to HHT. Her reason was because her
important post and handles outside dealings of the company and even now
they would contact her to sign checks and documents. She also said that
the company gives her 6 thousand each month and that she staying at a big
villa in town .Pt also said that she was married at 17 years old to a rich
man whom gave 1 acre of land worth 30 thousand and a huge banglo as
dowry to marry her. During the time when she was married to her
husband, she claims that some people were jealous and tried to ruin their
marriage and this includes the husband's own brother who tried to kill her
by using black magic from thailand and even tried to get her husband
married to someone else. After 23 years of marriage, the her husband
passed away but the reason could not be elicited as she believes that the She also denied being overly anxious about anything, having tremor,
husband is still alive and has gotten married to someone else. But now that palpitation, muscle tension, change in bowel habit, hot or cold intolerance,
she is staying in town, patient seem to have a strong belief that a group of history of head injury or seizure and denied taking any substance
men has been targeting her and repeatedly stealing her belonging like throughout her life.
handbag, handphone and other stuffs and treatened to harm her if she
Eventhough, she was fairly able to take care of herself and go to work
chases them. Apparently this has been going on for more many years and
during this period when she experienced these symptoms, patient has
she claims that the policemen are ignorant of her complaints and are bad.
however become more of a disturbance to the public as she would wander
Due to this, patient has been going around taking other people's stuff
around town and hang out at restaurants, scold random people passing by
claiming that it's hers and this eventually lead her to be arrested this time
and spit around, place her belonging outside people shop and has moreover
as she stole a lady's handbag in front of a bank and when police tried to
exhibited psychotic features as well due to her strongs beliefs.
arrest her, she ran and react aggressively. She was later sent to HSNZ
hospital and was later referred to HHT. Patient also has been giving away On the day of clerking, the patient's condition appeared to be somewhat
her money to children passing by and said that for the past 1 week plus stable , she still has delusions and some of the information she gave was
she would sleep for 2 or 3 hours only daily but did not feel tired the next unreliable but she was very cooperative throughout the interview.
day and had normal energy to carry out her daily activities. She however
Systemic review - unremarkable
denied having any special powers, being more talkative than usual, having
a subjective feeling of thoughts racing, being easily distractible or being Past psychiatric hx
involved in any goal directed activity. She also denied feeling depressed,
Patient was diagnosed with mental illness more than 20 years ago however
having loss of ability to feel pleasure from previously pleasurable activity,
the details on the first episode and what precipitated the illness could not
change of appetite or weight, feeling worthless, fatigue , inable to
be ilicited from the patient or her sister who has been contacted thro
concentrate, being restless,having slow thinking , having thoughts of
phone and a full proper history has still not been obtained yet.
suicide or attempts before. Denied hearing voices or seeing abnormal
figures.
She however has history of admission to HHT twice before, one in 2012 (
4 years ago) and another last year in 2014 for similar reasons. On both
admission she was kept in the hosp for more than 10 days and each time
after getting discharged she has defaulted her treatment and did not go for
follow up.
Past medical and surgical hx
No known chronic medical illness like diabetes, hypertension or asthma.
No past surgical history.
Family history
According to the patient, her father died while she was still young and so
she is not sure of the reason and later her mother remarried and left her and
her siblings. She is the last one out of three siblings, she has 1 older
brother and 1 older sister. after her mother remarried, the 3 of them grew
up at their relative's house.Currently her relationship with them is not very
good and she gets no support from them. Health wise,her older sister has
both hypertension and diabetes and the brother is well with no known
diseases. Otherwise, there is no family history of mental illness, substance
abuse or suicide.
Past personal history
Infancy :She was born by normal delivery with no complications.
Childhood: She had no developmental delays but she appears to have an
unhappy childhood as she lost a parent at a young age and her mother
remarried which eventually lead her to be brought up at her relative's
house All of this had come as a rejection for her as her own mother has
abandoned them. She however denies of experiencing any abuse or neglect
at the relative's house. She started school at 7, was able to make friends
with others and had a good relationship with her teacher and enjoyed
learning.
Adolescent ;
Much of the adolescent history was unreliable as patient claim that she
stopped schooling at 15 years old after inheriting a big company which she
had to take care of.
Adulthood: She got married at 17 years old and had 6 children but she
was widowed 9 years ago and since then she has lost contact with all her
children and do not know where they are now.
Forensic : She has no forensic history.
Current social situation
She is currently staying alone by herself around town with no fixed
accomodation, working as cleaner at a few places with a low-income of
10-20 ringgit from each place and even that is not stable and depends on
how much work she gets, every 2 weeks or so, she goes to her sister's
house to ask for money. She however does not smoke, take drugs or
alcohol.
Premorbid personality She says that her mood is normal lately.

attitude: She was a friendly person. Affect:

Habits: She used to be an athele before and liked to played sports.

religion: She had good faith in religion and prayed 5 times a day.
Perceptual disturbance
relationship: She had good relationship with her family and friends
previously. Patient has no hallucination or illusions
Mental status examination
Thinking
Appearance
(a) Form
Patient is a malay lady who appears to be in his late 40's with moderate
height and weight with greying hair at the side was sitting comfortably on
her bed with fair hygiene ,wearing clean hospital attire, there were no (b) Flow
frequent changing in posture and abnormal movements. She was friendly,
polite, cooperative and rapport was easily established with good eye
contact.

Speech: (c) Content

She spoke in malay and his language was relevant and could be
understood. The amount was increased with evidence of pressure of
speech however volume and tone was normal. Her reaction time to my
questions were however normal. (d) Possession

Mood : There is no thought insertion, withdrawal or broadcasting.

Cognition Vital signs

Patient is well oriented time, place and person. His attention is good as he Blood pressure: 144/87 mmhg
was able to do 100-7 substration test up to 5 levels. Immediate, recent and
Pulse rate : 87 beats per minute
remote memory was intact, as well as abstract thinking with good
information and intelligence level. He had good comprehension, fair Temperature : 37c ( afebrile)
general knowledge to his level of education with adequate arithmetic
Respiratory rate : 20 breaths per minute
skills.
Weight : 58 kg
Judgement
Height : 164 cm

Physical examination- unremarkable

Summary
Insight

Overall, patient has a very poor insight as she does not acknowledge the
fact that she has mental illness and is not keen on continuing her treatment
or going for follow up after her discharge.

Physical examination
Provional diagnosis
Patient was average built. He is alert, conscious and well responsive. There
Bipolar 1
were no abnormal facial features, abnormal posture or movements. He had
no medical instruments attached to him and did not appear to be jaundiced
or anemic.
Diffrential diagnosis

Management