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 sons 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 dont want to live.

FAMILY HISTORY
Patients 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 sons 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 patients speech was coherent
and relevant. The amount is slightly increased
but the volume, speed and tone was normal.
3 Mood/Affect patients 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

 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 patients social and

test judgment is good. However, her
personal judgment is poor as she
dont 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 ideas
which 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