CASE WRITE UP 1

PSYCHIATRY
YEAR 4
_____________________________________________

NAME : MUHAMMAD AMIRUL HAFIZ BIN

KHAIRUDIN

ID : 0120130100122

GROUP : ROTATION 5
LECTURES : DR HAITAM
: DR TIN
: PROF ZUL
DATE : 9TH JUNE 2017
IDENTIFICATION DATA :

Name : Mr. M

Age : 29-year-old

Sex : Male

Occupation : Unemployed

Race : Malay

Religion : Islam

Marital status : Single

Address : Meru, Klang

Date of admission : 28th May 2017

Date of clerking : 1st June 2017

Ward : Klinik Anika(Ward)

Informant : Patient himself and his father

CHIEF COMPLAINT :

Aggressive behaviour for 1 day

Odd behaviour for 1 week

HISTORY OF PRESENTING ILLNESS :

A 29-year-old gentleman with a known case of schizophrenia for 4 years, admitted to the
psychiatry ward (clinik Anika) after being brought by his brother to the hospital due to
aggressive behaviour by punching his neighbour for 1 day. Mr M claimed that his neighbour
keep mocking him as a mad person. Due to that, he unable to control his anger anymore and
unintentionally beating his neighbour severely.

According to his father, he noticed that his son as behaving oddly for the past a week prior to
the incident in which he was smiling and talking to himself. His father also noticed the
difference in the way he talked unlike in the usual days.. All of his family including his
sibling also notices he is not compliance to his medication where all his medication is till
untouched for 1 week. He also neglected his self care, as the family noted that he was not
having his bath for 2days. And sometimes he appeared untidy and smelly.

Mr. M also believes that everyone is talking bad about him and felt they could read his mind.
Apart from that, he felt that someone will hit him if he is walking alone in the
neighbourhood.

Beside that, he started to able hear the voices since being diagnosed with the illness 4 years
ago.. The voice was speaking in Bahasa Malaysia that kept talking to her almost every day
but not all the time. The voice talking and commenting like how are you today? have you
take your meal? why you wear this attire today? and you are beautiful today. However the
voice is not commanding in nature. He was conscious when he heard those voice. The voice
not only talking to him when he was alone but also when he watching television and with the
family members. He did asked her family about those voices whether they also heard those
voices. But, they said they did not heard the voice and did not believe him.

On further questioning, Mr. M denied seeing any images that others could not see. Otherwise,
he denied feeling depressed, had no changes in his appetite and weight, and had no
disturbance in sleeping pattern. He also did not experienced elevated mood or buying
unnecessary stuffs. He also denied feeling anxious, sweating, shaking, aware of his heartbeat
or difficult to breathe. Apart from that, he denied taking any alcohol or illicit substances prior
to the incident

PAST PSYCHIATRY HISTORY

He was diagnosed to have schizophrenia for the past 4 years. He has been taking a
medication. This is his 3rd hospitalisation to the ward since being diagnosed with the illness.
Previously, he was admitted due to odds behaviour. Mr. M claimed that he frequently attends
the follow-up and oftenly being accompanied by his father. Regarding the medications,
sometimes he skips the medication if his parents do not notice him because he claimed that
the medications has no effects towards him and only making him tired.
PAST MEDICAL AND SURGICAL HISTORY

Mr. M 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

He has been living with both parents since birth until now. Both parents are still alive and
healthy. He is the second child among the four siblings. He claimed that he has a very good
relationship with his family members saying that all of them love him so much and take a
good care of him. No history of mental illness running in the family. Currently, his mother is
having diabetes mellitus while the father is diagnosed to have hypertension. Otherwise, the
other siblings are well and healthy.

PERSONAL HISTORY

Prenatal / Perinatal events

Mr. M told that 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 Form 5. After completing his SPM,
he never went to further the study because had no interest. He claimed that he has a few of
friends during his school time and never involve in bully or truancy. Regarding the school
performance, he mentioned that he did not perform well in his school and has slight difficulty
following the teaching lesson.

Work history

Prior to the illness, he never had permanent occupation and kept changing his job for every 1-
2 years claiming that he wanted to gain more experiences by doing different kind of jobs.
Currently, he is unemployed and it is hard for him to get new job since he being diagnosed to
have the illness.
Psychosexual history

He is a single man. And denied having love relationship.

SOCIAL HISTORY

Mr. M lives with his parents in a village house at Paya Jaras. His father is a retiree and
occasionally doing some gardening in the neighbourhood. His mother is a full-time
housewife. All basic necessity is fulfilled. His brother and sister live in the nearby area and
often visit his parents home.

DRUG AND SUBSTANCES HISTORY

Currently he is taking tablet Risperidone once daily at night, however he sometimes defaults
the treatment if his parents do not notice of him taking the medication. This happens because
he claimed that the medication has no effect on him since he still can hear voice even after
taking the medication and feeling tired after taking the medication. Mr. M is non-alcohol
consumer and occasional smoker. He will only smoke if he goes out to meet his friends.

Otherwise, he denied abusing alcohol or illicit substances such as cannabis or amphetamine

prior to the incident

PREMORBID PERSONALITY

Mr. M described himself as a quite and shy person before the illness. He said that he has a
small circle of friends at his workplace and school. He preferred being at home watching
television or playing video games instead of socializing with friends.
MENTAL STATE EXAMINATION

A Malay gentleman who appears appropriate to his age,

moderate built and wearing the hospital attire.
His overall appearance is neat and clean, however his hair
General appearance appeared to be slightly messy and uncombed.
He is easily distracted when there is conversation around him.
No abnormal movements, no signs of anxiety such as 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 Malay fluently.

Speech He appears to be talkative, talking in slightly high volume and
rate.
Otherwise, tone of speech is normal.
His answers to some questions are irrelevant and sometimes
incoherent.

Mood His mood is euthymic since he mentioned that he is feeling good.

He has inappropriate affect but congruent to his mood.

He sometimes appears to be smiling when talking serious
Affect matters.

Thought form
There is loss of association noted during clerking, but no flight
of ideas or neologism noted

Thought content
Mr. M has persecutory and paranoid delusions in which he
Thought disorder claimed that everyone is talking bad about him and felt that
someone will hit him if he is walking alone in the neighborhood.
He also has thought broadcasting in which he felt everyone could
read his mind.
Otherwise, no suicidal, homicidal, depressive thoughts.
 Patient denied having any form of hallucinations during
the clerking. But he had auditory hallucinations for 4 year
prior to admission.
Otherwise, he denied having visual, tactile, gustatory or
Perceptual disorder olfactory hallucination.

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

Memory
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.
However, he did not pass the 5 minute memory test (score
1 over 3).

Attention and concentration

Cognitive function test Patient was not able to complete the serial subtraction test
of 100-7

General Knowledge or Intellectual

Mr. Ms 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. M has poor insight.

He does not believe that he is mentally ill.
Insight He also does not aware that all the symptoms experienced
are part of the illness process.
Besides, he also does not believe in treatment and the
medication given.
He claims that he only bluntly follows the doctors and his
parents instruction on taking the medication but insists
telling that he is mentally well.
PHYSICAL EXAMINATION

VITAL SIGNS

TEMPERATURE : AFEBRILE
BLOOD PRESSURE : 130/80 mmHg
PULSE RATE : 74 beats/min
RESPIRATORY RATE : 20 breath/min

GENERAL EXAMINATION

Mr M was comfortably seat on a bed.

He was alert, conscious, and well oriented to time, place and person.
His nutritional status and hydration status seems to be adequate
No bruises, needle marks or scars noted
He was able to cooperate during clerking and had a good eye contact.
His posture and movements were normal

SYSTEMIC EXAMINATION

No significant findings.
SUMMARY

A 29-year-old gentleman with a known case of schizophrenia for 4 years, admitted to the
ward clinic Anika after being brought by his brother due aggressive behaviour by punching
and beating his neightbour. According to the father, he noticed that his son as behaving oddly
for the past one week prior to the incident in which he was smiling and talking to himself as
well as talking differently than in usual days. Patient experiences second person auditory
hallucination since 4 years ago which is not commanding in nature. He usually ignores the
voice and only sometimes would talk back to the voice. Mr. M also believes that everyone is
talking bad about him and felt they could read his mind. Apart from that, he felt that someone
will hit him if he is walking alone in the neighbourhood.

Based on mental state examination, Mr. M appears to have disorganised speech. In general
appearance, his hair is slightly messy and uncombed. He is easily distracted when there is
conversation around him. He appears to be talkative, talking in slightly high volume and rate.
His answers to some questions are irrelevant and sometimes incoherent. He has inappropriate
affect. There is loose of association. Mr. M has persecutory and paranoid delusions. Besides,
he also experience thought broadcasting. He has been experiencing second person auditory
hallucination for 4 years and recently the voice had become commanding in nature. For
cognitive function tests, Mr. M has fair concentration and attention as well as fair immediate
memory (5 minute). He also appears to have poor insight.
DIAGNOSIS

Provisional diagnosis

Relapse schizophrenia due to incompliance to medications

- A known case of schizophrenia

- Pyschosis symptoms :

- Second person auditory hallucination for 4 years

- Delusion
Diagnostic criteria of
- Disorganized speech schizophrenia based on
- Incoherent speech DSM-V
- Inappropriate mood
- Loose of association
- Poor insight
- Thought broadcasting
- Incompliance to medication
- Symptoms affect work and interpersonal relations (unemployed)

Differential diagnosis

Diagnosis Supporting points Against points

Substance-induced psychotic - Hallucination (auditory) - No history of substance

disorder - Delusion abuse
- Disorganized speech

Schizoaffective disorder - Hallucination (auditory) - No depression symptoms

- Delusion - No manic symptoms

Medical Condition induce -Hallucination No medical illness

psychotic symptom

Delusional disorder - Delusion - Hallucination (not

related
to delusional theme)
- Disorganized speech
- Functioning in life not
significantly impaired
MANAGEMENT

Patient setting

- Inpatient because his action on setting his house could harm others especially his
parents

Investigation

Laboratory investigations :

- Aim : To rule out substance abuse or medical illness causing psychosis as well as to
monitor the side effects of the antipsychotic medications

- Urine drug testing (Urine analysis) : To rule out substance abuse that induces
psychotic symptoms

- Thyroid function test : To rule out thyroid disorder

- Full blood count

- Renal function test To monitor the side effects of the antipsychotic medications
- Liver function test throughout the hospitalisation
- Lipid profile

- 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. Besides, EEG rarely necessary unless history
of seizure or symptoms suggesting temporal lobe epilepsy.

Psychosocial investigation :

- Assess family support

- Obtain history from family
- Consult with patient close friends and colleague with patients consent
- Risk assessment for aggressive behavior
Pharmacological treatment

Acute management : IM Haloperidol 10 mg stat, prn

IM Midazolam 5 mg stat, prn

Inpatient management : Tablet Olanzapine (Zyprexa Zydis) 5 mg, bd

Consider depot preparation when treatment adherence issue arises to prevent relapse
secondary to incompliance to antipsychotic drugs.

Non-pharmacological treatment

Psychoeducation :

- It is important for the patient and his family. They should be provided with accurate
information and details because of the long-term nature of the disease. Educate on the
importance of taking medication with the consequences of not compliance, early
warning signs of relapse recognition and prognosis of the disease. Besides, provide
information to the family on crisis management strategies. In this case, stress more on
compliance since it could be the reason of the relapse schizophrenia.

Psychotherapy :

- Cognitive Behavioral Therapy : To help patient copes with persistent delusion and
hallucination.
- Supportive psychotherapy : Include advice, reassurance, education, modeling, limit
setting, and reality testing. Involves a heavy reliance on the therapeutic relationship,
with instillation of hope and imparting of information.
- Group psychotherapy : Focus on support and social skills development. Helpful in
decreasing social isolation and increasing reality testing

PROGNOSIS

Prognosis for Mr. M will be fair prognosis since he having equally for both good and bad
prognosis factors . The table shows the factors that contribute to Mr. Ms prognosis.

Factors of good prognosis Factors of bad prognosis

- Good social support as he claims his - Male sex
family take a good care of him - Poor premorbid personality (social
- Positive symptoms withdrawal)
- Few relapses (3 times within 4 - Single
years) - Poor insight
- No family history of schizophrenia
DISCUSSION

Schizophrenia is a syndrome of unknown aetiology characterised by disturbance in

cognition, emotion, perception, thinking and behaviour. The lifetime prevalence of
schizophrenia has generally been estimated to be approximately 1% worldwide. The disorder
is usually chronic, with a course encompassing 3 phases which are prodromal,
active/psychotic and residual phases. The schizophrenics have symptoms such as
hallucinations, delusions, and disorganised thinking in the active phase and usually this is the
hallmark symptom of schizophrenia. There will be attenuated forms of active symptoms
during prodromal and residual phases.
Symptoms of schizophrenia are typically divided into positive and negative symptoms
because of their impact on diagnosis and treatment. Positive symptoms are those that appear
to reflect an excess or distortion of normal functions including hallucinations, delusions,
bizarre behaviour, or thought disorder whereas the negative symptoms are described as
blunted affect, anhedonia, apathy, and inattentiveness. As for this case, Mr. M has the
positive symptoms of schizophrenia. This is because he has been experiencing auditory
hallucination, persecutory delusion, thought broadcasting and appeared to have disorganised
thinking/speech based on the mental state examination.
Schizophrenia is a clinical diagnosis, however no single symptom is definitive for the
diagnosis. The diagnosis can be only made if it meets the diagnostic criteria as per listed in
the DSM-V. Amongst important criteria to be considered in diagnosing schizophrenia
according to DSM-V are the duration of the symptoms as well as to rule out other possible
causes of psychoses such as substance abuse, medical illness or other psychiatric conditions.
For this patient, he was diagnosed to have schizophrenia since he had fulfilled the criteria for
the diagnostic features of schizophrenia based on the symptoms that he had experienced so
far such as auditory hallucination and delusion for almost 4 years since the first time being
diagnosed to have this illness.
The Dopamine Hypothesis is the well-known theory in describing the
pathophysiology of schizophrenia. This theory demonstrates increased level of dopamine
activity in certain neuronal tracts and it is supported with the evidence that most of
antipsychotics that are successful in treatment of schizophrenia are dopamine receptor
antagonists. Therefore, antipsychotic is considered as important pharmacological therapy to
treat patient with schizophrenia. There are typical and atypical antipsychotics available to be
used, however atypical antipsychotics are more preferable due to much lower incidence of
extrapyramidal side effects (dystonia, pseudoparkinsonism and akathisia). As for Mr. M, he
received atypical antipsychotic which is the olanzapine to treat his condition.
The management of schizophrenia is not only limited to the pharmacotherapy, a
multimodal approach is the most effective way to treat the condition. The therapy also must
be tailored to the needs of the specific patient. For the non-pharmacotherapy part,
psychotherapy as well as psychoeducation being the important modality in improving
psychosocial aspect of patient with schizophrenia. In this approach, important points will be
emphasised to both patient as well as the family to improve patients condition. As for Mr.
M, psychoeducation involving him and his family members will be the important therapy to
improve his adherence and compliance to the medication so that the episode of relapse could
be controlled or even avoided in the future.
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American Psychiatric Association, 2013. Print.
4. "Schizophrenia: Practice Essentials, Background, Pathophysiology".
Emedicine.medscape.com. N.p., 2016. Web. 7 Nov. 2016.
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