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Patients Details

Name: Mrs. Audrey Wong


Age : 34 years old
Race : Chinese
Gender: Female
Address: Kamunting, Perak
Marital Status: Married with 2 children
Occupation: Housewife
Date of Admission: 16 August 2015
Date of Clerking: 19 August 2015
Source of Referral: She was brought in by father and elder sister.
Chief Complaint: Attempted suicide at home.
History of Presenting Illness:
Mrs. Audrey with no known comorbids was well until 6 months ago when she started
to feel depressed as she had trouble with her husband who was a drug addict and was found
to have a mistress later on. Her problem started about a year ago when her husband
occasionally comes home early in the morning which made her suspect that her husband was
on drugs as the husband started to behave strangely and occasionally shouting in the
bathroom at night talking through the phone with his friend. She tend to ignore that matter as
she claim that initially her husband takes them only about once a month and she did not want
to interfere as she knows that her husband has been through a lot of stress lately earning
money for the family. Plus, the husband was not aggressive towards the family. However, few
months later the matter became worst as her husband started to take the drugs frequently and
only came home once every 2 to 3 days. She claim to have advice the husband about it a
couple of times and they ended up quarrelling with him shouting at her and leaving the house
for about a week.
Later on, she started to become depressed as her husband rarely comes home and felt
as though her relationship with her husband was growing apart. Initially, she was sad only
when she thinks about her husband but it became worst as time passes. Now she claim that
her low mood was persistent throughout the day and worst during the day especially in the
morning when she wakes up. Her depressed state has been persistent almost everyday for the
past 6 months. She was said to have difficulty sleeping since early this year for about 6
months. She claim that she was only able to sleep after 2 hours lying on the bed constantly
thinking about her husband but denied waking up in the middle of the night. However, she
has been waking up about 2 hours earlier than her usual waking time. She would often feels
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tired due to the lack of sleep and was easily irritable especially with her husband and her
children who was still young.
About 2 months ago, she found out that her husband has been keeping in touch with a
lady who claimed to be his mistress. The mistress was said to have contacted her and
threatened to steal her husband. When she questioned him further about his affair he denied it
and ended up slapping her and left the house. He did not come home for the past 2 months
and she had no way of contacting him. Her depression became more severe as she started to
develop lost of interest in her usual pleasurable activity such as meeting up with her friends
and family. She claim to even rarely step out of the house since her parents move over to help
her with her children such as sending them to school and tuitions. She claim to have lost of
appetite and lost about 5 kg of her weight for the past 2 months. She felt hopeless and
worthless as she felt her marriage was falling apart and guilty towards her children. She was
constantly feeling lethargic. She claim to stop cooking but her mother had move in to her
house recently cooking for the family. About two weeks ago she started having suicidal
ideation occasionally as she felt that her life was not worth living anymore but had never told
anyone about it. She claim to have listen about people trying to suicide by taking pills
through news and was considering to do so. But she was scared if it did not work she would
need to suffer the consequences. In the end, she had resorted to hanging herself. That night
around midnight when she had made sure that all her family member went to bed she decided
to carry out her plan in her room quietly. She had left a suicide note on the table next to her
bed. Then, she took the cloth that she bought especially to hang herself and tied it to the fan
on the ceiling. Fortunately, few minutes after she hang herself her daughter came in her room
wanted to use the toilet and found her. The patient was found unconscious and was rush
immediately to the Accident and Emergency Department by her family members. She claim
to feel regret when she found herself waking up in the hospital.
Besides that, patient claims to have difficulty concentrating with her daily activity as
she is constantly worried about her marriage and the future of her children and herself for the
past 6 months. She was also anxious and scared thinking about a life without her husband
who has been supporting the family financially throughout their marriage life and that she has
to return to work after being a housewife more than 10 years. Her worries was often
associated with headache and sometimes find it difficult to breath. She finds it difficult to
control them as her mind was constantly preoccupied with her problems. She tends to feel
tensed up and has been restless for the past 6 months. She denied experiencing an episode of
sudden rush of intense fear or discomfort that felt as though she was about to get a heart
attack or fear that she might lose control. She denied feeling anxious about using public
transport, being in public or being away from home alone. She denied experiencing fear in
social situations or fear of anything else.
She denied of seeing things, hearing voices, feeling strange body sensation, smelling
or tasting things that normal person dont. She denied of feeling someone trying to harm her
or having any special power. Sometimes, she felt that the TV was spying on her. She also
denied of something trying to influence her, thoughts being read by others, being inserted by
someone or feeling thought being removed by someone.
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She denied of having other mood symptoms such as elevated mood, distracted easily,
being talkative and conducting pleasurable activity with painful consequences. Patient denies
taking drugs nor drinking alcohol.

Past Psychiatric History


This is Ms. Audrey first encounter with a psychiatrist and also her first admission to HRPB.
However, patient claim to had similar episodes of depressed mood with difficulty in sleeping
after her first pregnancy but was not that severe to the extend of committing suicide. She did
not visit the doctor nor did she never received treatment for it as she thought it was just
normal reaction to stress. That episode was said to last a few months. Patient refuse to discuss
any further about it as she claim it was a long time ago.
Past Medical and Surgical History
She has undergo appendectomy 8 years ago in HRPB with no surgical complication. She has
no significant past medical history.
Family History
72 y/o, DM HTN

70 y/o, HTN

35 y/o

34 y/o
Passed away due to road traffic accident
45 y/o

39 y/o

15 y/o

11 y/o

Ms. Audrey is the youngest child out of 4 siblings. Both her parents are still alive with her
dad said to be suffering from heart problem and hypertension and her mother was known to
have diabetes and hypertension. Her second elder brother passed away due to road traffic
accident 5 years ago. Otherwise, she denied any mental illness in the family or any known
family members who had suicide or was brought to see a psychiatrist. She claim to have a
good relationship with her parents and siblings and she frequently seek help from them
especially when her husband was not around. Her children was also Her husband worked in
Kamunting as a businessman.
Personal History:

Birth History:
She was delivered by normal vaginal delivery. There is no significant birth history, nor any
delay in her developmental milestones. She was generally healthy during her childhood and
denied any history of epilepsy. She was a family-bound person.
Academic Records:
She started schooling at the age of 6 and manage to finish her studies in high school.
Throughout her school years, her academic record were average with grades of Bs and Cs.
She manage to score 1 As 3 Bs 2 Cs for her PMR and scored 2 As, 5 Bs and 2 Cs for her
SPM. She claim to be a popular kid with many friends. She used to an athlete in her school
badminton team and represents school in olahraga. She denied being involve in truancy,
bullying or being bullied by others. She denied smoking or being involve in drugs.
Work History
Patient started working at the age of 20 years old as a clerk because during that time
her husband has just started his business and they were financially tight. She claim to have
many friends in the office and was quite close to them as she occasionally goes out with them
for some coffee. However, she stop working after 3 years as she was pregnant with her
second child. Then, she has been a full time housewife ever since preoccupied with her
household and her looking after her children at home for the past 10 years.
Sexual History
She reached puberty at the age of 11. Her menses was regular, lasted for 4-5 days in
25 to 28 day cycle. She had no dysmenorrhea but menorrhagia since end of 2014 with fresh
blood without blood clot seen. She used 3-4 maxi pad every day during menstrual period. But
her menses were irregular for the past 8 months with her period only coming every 2 to 3
months once. She is heterosexual. She claimed that she was loyal to her husband.
Hobbies and habits
Her hobby was playing cooking, travelling and shopping. However, she had loss of
interest towards her hobbies currently. She denied of any alcohol and drug abusing. She do
not smoke.
Marital History
Ms. Audrey got married at the age of 18 years old after she finish her studies. It was a love
marriage. They had been together for about 3 years before they got married. She described
her husband used to be a gentleman and a responsible man but later on changed to be
impatient and loses temper easily due to the influence of the drugs. She conceived their first
born after 6 months of marriage and her daughter 4 years later. Currently, her son is 15 years
old and her daughter is 12 years old. She loves her both of her children and was very proud of
them as they were both clever kids with no problems in school. Her children are also obedient
are rarely cause her trouble to manage.
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Premorbid Personality
She was a cheerful and extrovert. She was a religious person and always went to the
temple to pray. Occasionally, she will hang out with her high school friends and previous
clique from her last job. She loved travelling with her family members and she claimed that
she had travelled to most of the places in Malaysia and nearby countries such as Thailand,
Singapore and Korea. She claim to be coping well with stress mainly by shopping and
cooking. She denies being an impulsive person and denies any self harm acts such as cutting
her wrist.

Mental State Examination


Physical appearance: She was on hospital attire, good hygiene, well-kempt and wellgroomed with normal posture.
Motor Behavior: She had poor eye contact, no mannerism, no tics, not restless and not
agitated.
Attitude: She was able to cooperate. Her speech was forthcoming, relevant, coherent and
rational. She was not guarded and not distracted to the surroundings.
Talks: She talked softly and slowly. She spoke in English throughout the interview. Her tone
was normal. Well-articulated speech. No word salad. No flight of ideas. No looseness of
association. No thought block. No tangentiality and circumstantiality. No neologism
Mood: Depressed mood
Affect: Constricted affect.
Affect congruent with her mood. She cried twice during the conversation (Labile).
Thought content: No poverty of thought
No grandiose, jealousy, persecutory delusion.
No suicidal thought
Perceptual disturbance: No hallucination
Sensorium and Cognition: She was alert and conscious.
Orientation: Well oriented with time, place and person.
Attention and Concentration: Poor as she was not able to do serial seven test and was
unable to spell WORLD backwards. She was able to complete the digit span test with great
difficulties but she was able to recall 4 digits forwards and 3 digits backwards.

Memory:
Good Immediate memory and memory as she was able to repeat lemon,
computer and bicycle immediately and 5 minutes later. Her recent memory and remote
memory was intact as she was able to recall events past the few months and able to recall
childhood and schooling events respectively.
Information and Vocabulary:
She had good general knowledge as she was able to name our Prime Minister, Dato Sri Najib
bin Tun Razak and she was able to name the national anthem which was Negaraku.
Abstract:
Good abstract.
She was able to explain the similarities and differences between chair and table, apple and
banana. She was to explain simple english proverbs.
Judgment:
Good judgment. Patient claim that she will start to think positive and manage her life
properly from now on and avoid having suicidal thoughts. She was able to justify that she
would call the fireman and run out of the house if her house were on a big fire.
Insight:
Good insight.
She knew that she had depression disorder and was aware of the symptoms. However, she
knows that her symptoms can be controlled by taking medication and she is willing to
comply to medication.

Physical Examination
General examination
Patient was sitting comfortably on the chair, conscious and alert and not in respiratory
distress. She is slightly underweight.
Vital signs:
a)

Blood pressure : 120/65 mmHg

b)

Respiratory rate : 16 breathe per minute

c)

Temperature : 37 degree

d)

Pulse rate

: 92 beats per minute, regular rhythm and adequate volume.

Her hands are warm and pink and capillary refill time was less than 2 seconds. No nicotine
stain, no clubbing and no peripheral cyanosis. No tremor and there was no track marks on her
extremities. Her conjunctiva was pink and there was no yellow discolouration of the sclera.
No proptosis, no nystagmus and no lid lag on eye examination. No central cyanosis seen on
his lips. His oral mucosa was well hydrated and no mucosal jaundice.
Cervical lymph node was not palpable. No palpable thyroid swelling on her neck. No
proximal myopathy.
Nervous system examination
Patient was well orientated with time, place and person. Her higher mental function was
intact as he was able to write, read and answer question accordingly. Her cranial nerves was
intact. Her gait was generally normal with no signs of bradykinesia, incoordination and
ataxia. Her tone, power, reflex and sensation of his extremities were normal.

Cardivascular examination
Inspection
There was no surgical scar, no dilated veins, no visible pulsation and chest wall was normal
in shape. Jugular venous pressure was not raised.
Palpation
Apex beat was on the 5th intercostal space mid-clavicular line. No thrills felt and there was no
parasternal heave.
Auscultation
1st and 2nd heart sound was heard, no murmur. Carotid bruit was not heard.

Respiratory examination
Inspection
There was no skeletal deformity, no surgical scar and no dilated veins.
Palpation
The trachea was centrally located. Apex beat palpable at the 5 th intercostal space, mid-axillary
line. The chest expansion was equally normal on both sides and tactile fremitus was equal on
both sides.
Percussion

Percussion note was resonance and equal on both sides of the lungs in the upper, middle and
lower zone.
Auscultation
Vesicular breath sound was heard over the upper and middle lobe. No added breath sound.

Abdominal Examination
Inspection
Abdomen was much scaphoid and moves well with respiration. No surgical scar, and no
dilated veins. Umbilicus was inverted.

Palpation
Abdomen was soft and non-tender, no guarding, no rigidity, no palpable mass.
Liver was not palpable. Spleen was not palpable and traube space was resonant. Kidney was
not ballotable.
Percussion
Shifting dullness was negative.
Auscultation
Bowel sound was normal, renal bruit was absent.

Provisional Diagnosis: Major Depression Mood Disorder with anxious distress.


Differential Diagnosis:

Adjustment disorder with mixed anxiety and depressed mood


Generalized anxiety disorder

Management Plan
1. Patient need hospitalisation as she is at great risk of self harm and suicidal.
2. Call up the family members if possible to get more details about the patients illness and
to explore patients family understanding towards patients condition.
3. Routine blood tests such as full blood count, liver function test, renal profile, fasting
blood glucose, and before any medication was prescribed.

4. Run a thyroid function test since the patient has symptoms of anxiety.
5. In the hospital setting, the following medications were prescribed:
-Tablet Lorazepam 1mg BD for 1 day, taper Lorazepam to 1 mg ON, then stop Lorazepam
depending on the patients condition.
-Tablet Fluoxamine 100 mg ON
6. Psychotherapy such as cognitive behavioural therapy and crisis intervention should be
recommended to patient.

Discussion
According to DSM V, Ms. Audrey seems to fulfil the criteria of Major Depression
Disorder with anxious distress as she presented with a persistent low mood for the past 6
months which occurred nearly everyday with diurnal symptoms. Initially, Ms. Audrey
depression was mild as she was only feeling depressed which was associated with difficulty
in sleeping, feeling lethargic and irritable. It was not sufficient to fulfil the Major Depressive
Disorder Criteria as she only fulfil 4 instead of 5 criteria that is needed and there was no
significant impairment in functionality as she was still able to carry out her roles as a
housewife. However, as her problem started to become worst in addition to her knowledge
about her husband new mistress that was jeopardising her marriage, she started to exhibit
more symptom such as anhedonia, psychomotor retardation, feeling hopeless, worthless and
guilty, lost of appetite and lost of 5kg of weight for the past 2 months.
Along with her depressive symptoms, Ms. Audrey also manifested anxiety symptom. She
clearly had difficulty dealing with her problem causing her to be anxious about her marriage
and future. She constantly felt tense up, restless and had difficulty concentrating with her
daily activities as she was constantly worried about her relationship with her husband and his
mistress. Her greatest fear was her husband leaving her and her children as not only he was
their only source of finance but she finds it hard to start working again as she had stop
working for a very long time. She was also afraid of losing her children to her husband if they
were to divorced as her husband was more capable of looking after them.
Another factor supporting Major Depression Disorder is the fact that she had similar but mild
episodes after her first born child possibly suggestive of postpartum depression. However,
patient was unable to recall much about that episode as it was long time ago and she was
never diagnosed with it as she never seek for medical attention and that the depression lasted
only about a few months.
As for suicidal risk assessment, Ms. Audrey seems to show a great risk of suicide as
she is currently in a depressed state and preoccupied with mixed feelings of hopelessness,
worthlessness, guilty and anger in her. Furthermore, her previous attempt of suicide was well
planned with her buying a cloth making sure it was suitable to use for hanging herself at the

time where everyone was asleep. She even left a last note for her families. She also shows
regret that her suicide did not succeed. Possibility of Ms. Audrey reattempting her suicide is
quite high especially with improper assess to counselling and support. She should be
hospitalised and monitor her behaviour with thorough reassessment before discharging her.
Her family members seems to show great support and a strong connection between she and
her children and parents are protective factors that could help to mitigate the risk of suicide in
her. Her family member should be advice to frequently visit her and advice her on her
suicidal ideation. With good support and treatment, patient might be able to rethink on her
suicidal plans and instead considering starting a new life with her children and a new job.
Besides prescribing patient with antidepressants, psychotherapy such as crisis
intervention and cognitive behavioural therapy (CBT) will be of great help to Ms. Audrey.
Cognitive behavioural therapy is essential in depressed patient as it helps to change patient
mindset and thinks positively leading to a more positive attitude and behaviour towards life.
Crisis intervention on the other hand will help her to manage her stress and her relationship
problem with her husband by suggesting her ways she can deal with the stress her husband
has caused her. It may help to encourage her to find a job by guiding her through it. A couple
therapy may be given if the husband is willing to join the session and it will help to solve the
problem that exist in their relationship and resolve the current issue. They should be made
aware that it is essential to solve the problem that lies ahead instead of avoiding them leading
to more severe consequences.
The main differential diagnosis in this patient will be adjustment disorder with mixed
anxiety and depressed mood because as she develop emotional and behavioural symptoms
such as low mood, anhedonia, psychomotor retardation and anxiety in response to her
husband drug addiction problem and the existence of a new mistress ruining her marriage
which was the stressor. The symptoms develop within 3 months of the onset of the stressor.
However, the symptoms patient complains of fulfil the major depressive disorder as her
mood symptoms predominates throughout the whole 8 months with development of other
symptoms only later on. Plus, patient seems to have a history suggesting of postpartum
depression causing the diagnosis of major depression disorder more likely as patient is at a
higher risk of getting depression.
On the other hand, generalised anxiety disorder is another differential diagnosis that
should be consider in Ms. Audrey as she too manifest anxiety and worry for the past 6 months
She finds it difficult to control them as her mind was preoccupied with her problems. In
addition to this, she has associating symptoms such as being restless, irritable, tense up,
difficulty in concentrating and also sleep disturbance. However, in her case depressive mood
symptoms seems to had manifest earlier and was more prominent in this episode compare to
her anxiety symptoms which came along with it. Besides that, anxiety and depression
secondary to hyperthyroidism and hypothyroidism respectively should be considered and
need to rule out through the thyroid function test done and physical examination of the neck
to palpate for thyroid swelling. There was no palpable swelling on Ms. Audreys neck and
clinical signs of hyperthyroidism such as fine tremor, lid lag, proptosis and proximal
myopathy were also negative.
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