Long case (schizophrenia)

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Long case (schizophrenia)

  1. 1. 1 NAME: NABILAH BINTI DATO’ AYOB NIM: 060 100 814 GROUP: H4 DEPARTMENT: PSYCHIATRIC ______________________________________________________________________________ 1. PSYCHIATRIC HISTORY  IDENTIFICATION Name : Wan Haliza binti Wan Nan Age : 32 years 9 months Sex : Female Marital Status : Married as second wife with 2 child Religion : Islam Educational level : Diploma of Accounting Address : KM 6, Jalan Kaki Bukit, 01000 Kangar, Perlis Occupation : Pembantu Tadbir, Jabatan Insolvensi Source of referral: Klinik Ehsan Phone Number : 04-9766796  CHIEF COMPLAINT(S): Duration  A few days ago (4-5 days) Patient came because she felt no spirit, unhappy, tired and very sleepy.  HISTORY OF PRESENTING ILLNESS: The patient complaints started a few days ago, she said she was concern about her eldest sister who was previously married and now had been divorce. Currently her sister and the family are living with her under one roof. She mentions that her sister have schizophrenia since childhood, and that she was really worried about her sister
  2. 2. 2 life. She also mention that she was worried if the same thing will happen to her and this brought her to feel no spirit, tired and also worried. She was feeling sleepy and tired even when it is in the morning, she explain that she will sleep from Maghrib prayer time till the morning and still feel tired. She said even without the medication, she still feel sleepy and tired. The patient onset of illness started in 1996 when she was in her early adult age of 19. She was a college student who rented a house in Selayang mansion, she was having problem with the landlord. The landlord all of a sudden, rented the house to a group of boys without telling her. The landlord also locks the house door using a new key and that she can’t come into her house. Because of this event she develop the symptoms of anxious when in a crowded place and in tense situation, low mood, sleepless, not stable, loss of appetite, dizzy, and feeling weak in doing activities even a simple one. She also said that because of the problems she feel like they are animal that can understand to what she’s saying. She did specify that there is a bird (burung gagak) speaking to her about her problems and give advice to her. Beside the bird she also claims that she can talk to the cats as well. She explains that she never had a rough situation in her life before and that is her first time accounting a problem by herself. During that time her parent only brought her to see bomoh and ustaz to cure her but, she said there were no improvement with her condition. Later in December 1997 after a year with duration of untreated illness, her family then brought her to see general practitioner from Clinic Ehsan in Kangar to seek a professional help. She is then being reffered to Psychiatric Department in Hospital Tuanku Fauziah (HTF). She then has been given medication due to her illness. She did mention about being hospitalized for a week for her illness but she can’t remember when it was. In 2003, she married as a second wife. She married willingly to her husband and knows that her husband has a wife before her. She was living in Putrajaya and work there as a government servant. Her husband knows about her mental illness condition and supportive. She drives from Putrajaya to Kangar back and forth for her regular follow up.
  3. 3. 3 After a year in 2004, she was pregnant with her first child. She was very happy to have the baby. She delivers the baby in HTF, but her baby has to be treated in NICU for about 3 weeks. She then said she had a suicidal thought at that time, she said she feel worthless and does not deserve to live anymore. She tries to commit suicide by overdosing her drugs. In 2007 she transfers her work to Perlis. She transfers from the Custom Department in Putrajaya to Insolvency Department in Kangar. She said she had difficulty to adjust to her new office environment. She has problems to get along with her colleagues and her boss. This was due to her current condition which her colleagues did not understand. She often asks for leave and always have medical certificate for her illness and yet her colleagues did not believe her. They see her as a normal healthy person that did not need to ask for a leave. She felt unhappy for this and usually she was alone in the office doing her work and did not talk much during working period. She felt her colleagues did not like her, and feel going to work is a burden to her. She also mentions that her relationship with her husband is not so good. Her husband currently works in Kuala Lumpur and only came to see her once every two weeks. When ask about did her husband give her living expenses, she said her husband did not miss it. But she did mention that she rather her husband did not went back to Kangar at all to see her, because it just give her burden. On 2008, she was pregnant with her second child. She mentions that her husband did not give enough attention despite of her pregnancy. She feels that the first wife has all of her husband life. She feels she can’t move on anymore and again try to overdose herself with the medication even when she was pregnant. Despite the suicide attempt, the baby was delivered normal. During the period from 2009- Early 2010, she continues her follow up in HTF and sometimes will come to the psychiatric department to tell her problems. Mostly her problem evolves around her workplace and family. Until recently she came to the Psychiatric Department to complain about her current condition of unhappy, felt no spirit, tired and very sleepy.
  4. 4. 4  FAMILY HISTORY: She still has both of her parents, who are still married. His father is 72 years old and her mother is 70 years old. Her mother is also the second wife to his father. Her father currently not working and his health condition is not good because he were having diabetes mellitus, high cholesterol and heart problem. Her mother who is also not working has high blood pressure and asthma. Her relationship with parents are good, and they are currently living together with the addition of her elders sister family recently. She did not get along with her eldest sister very well since her sister suffers from schizophrenia. Her relationship with her second sister is good. 72, DM, Hi Cholest, 70, Hi BP, Asthma Heart 42, Schizo 39, Anxiety 33 6 2  FAMILY PSYCHIATRIC HISTORY: Her eldest sister is currently suffered from schizophrenia. Her eldest sister had suicide attempts several times but is saved. Her second sister had anxiety problems.
  5. 5. 5  PERSONAL HISTORY i. CHILDHOOD D.O.B : 6 May 1977 Place Of Birth : Kangar Abnormalities to or at birth (e.g. premature labour) : - Childhood health/hx of nervous problem: She stated that she does not suffer any health problem in her early age except for her sprained ankle. Early emotional stress : The illness of her eldest sister. ii. EDUCATION Age beginning schooling: 6 years old School attended : -Sekolah Kebangsaan, Sekolah menengah kebangsaan, College ITTAR Relationship with peers and teachers: -She said that she did not care about the environment, she is a loner, always by herself, did not have any bestfriend during her schooling years, and are not close to her teacher. History of truancy or other trouble or difficulty at school: None Qualifications achieve: Diploma in Accounting Age leaving school: 21 years Higher education: College taking Diploma
  6. 6. 6 iii. OCCUPATIONAL HISTORY As mention earlier she did not enjoy her work. She felt as if it was a burden. Her colleagues did not like her and she felt that her boss to. She said that her colleagues often talking about her at the back and saying that she is a liar because she always asks for a leave. Previously she work at Putrajaya in Custom Department and then ask for transfer to Kangar to live with her mother and it is easy for her to come for her follow up in HTF. She always feel tired and sleepy at her work place and did not have any close friend. iv. RELIGIOUS BACKGROUND She follows her religion accordingly but sometimes she said she missed the solat. v. PSYCHOSEXUAL HISTORY Age menarche : 11 years old Menstrual Abnormalities: None since she is on her birth control pills History of pregnancy : G2P2 Sexual orientation : Heterosexual Sexual physical abuse history: None Sexual difficulties: None vi. CURRENT SOCIAL SITUATION With whom live : -Living with both her parents, her eldest sister and her child, her children Occupational and financial status: -Still working as a government servant and she stated her salary is not enough to support she and her family Nature and suitability of accommodation: `To many people living in her house, she felt uncomfortable with it. Hobbies and social interest: Watching Tv, Listening to the radio
  7. 7. 7  PAST MEDICAL HISTORY Physical disorder: None Injuries: none Medication side effect: Sleepy, she felt as her head blank after woke up from her sleep after taking medication. Metabolic illness: (heart failure/ kidney/diabetes/hypertension) -She said she had diabetes in her pregnancy but now she did not do any regular checkup and did not know her condition currently.  PSYCHOACTIVE SUBSTACE USE Alcohol : None Tobacco : None Illicit drug abuse: None 2. MENTAL STATUS a) APPEARANCE i. PERSONAL IDENTIFICATION Wan Haliza is a 32 year old Malay woman, she appear as her age is. She was fairly groomed, wearing a scarf that suit with her Baju Kurung. She did not wear any make up and looking very tired and sleepy. ii. BEHAVIOR AND PSYCHOMOTOR ACTIVITY She sits normally but put her hand on the desk to hold her heads up as if she was really sleepy.
  8. 8. 8 iii. GENERAL DESCRIPTION Overall she is well dress and cooperative during the interview even though she is tired and sleepy. b) SPEECH She at a normal rate and in normal quantity, no neologism detected throughout the interview, she speaks in “utara/Perlis” dialect. The form is also ok. c) MOOD AND AFFECT i. MOOD When asked about her feeling today she said she feels tired and no spirit. Her mood was slightly depressed. Her mood is appropriate with the thought content. ii. AFFECT Her affect appears appropriately to what she is saying, and changes when it is sad or happy but seem restricted to her restless state at the moment. d) THINKING AND PERCEPTION i. FORM OF THINKING  Productivity The patient productivity of thought is good. She answered spontaneously and often elaborate the answer  Continuity of thought Patient answer the questions and are goal directed.
  9. 9. 9 ii. CONTENT OF THINKING  Preoccupation: None iii. THOUGHT DISTUBANCE  Delusion: Currently patient does not have any delusion. In previous history, patient use to have grandiosity delusion. She said she was able to make anything she sees as her own thing. For example if she sees a book that belongs to her friend she will use her power to make it hers instead.  Ideas of references and ideas of influence: None iv. PERCEPTUAL DISTUBANCE  Hallucination and illusion: Currently she did not experience any hallucination. But previously, the patient use to have hallucination that she could talk to a bird specifically (Burung Gagak) even if it is not there. She claims that the bird can understand her feelings and help her. Besides the birds, she also said that she can talk with animal. This is a second person hallucination and its happen that she had auditory and visual hallucination as well.  Depersonalization and derealization: None v. DREAM AND FANTASIES  Dream : -  Fantasies :-
  10. 10. 10 e) SENSORIUM i. ALERTNESS: The patient appears alert and co-operative. ii. ORIENTATION She is orientated to time, place, and person. iii. CONCENTRATION AND CALCULATION Patient is able to recite months in a year backwardly and also can count the subtraction of seven started from 20-7 with no difficulty at all. iv. MEMORY  Remote memory : Good  Recent past memory: Good  Recent memory: Good  Immediate retention and recall: Memory is very good for immediately recall of all three object ‘kotak, pokok, pasu’. She also can recall all of it even after 5 minutes. v. FUND OF KNOWLEDGE Good. Patient recalls the neighbor of Malaysia such as Thailand, Indonesia, Filipina, Laos, Cambodia and Singapore. She also know who is the recent Prime Minister which is Datuk Najib bin Tun Razak. vi. ABSTRACT THINKING Good. When asked about proverb of “Alang-alang menyeluk perkasam, biarlah sampai ke pangkal lengan” she can interprets it correctly. f) INSIGHT Good. Intellectual insight. Awareness of being ill and that the symptoms/failures in social adjustment are due to own particular irrational feelings/thoughts; yet does not apply this knowledge to the current/future experiences.
  11. 11. 11 G) JUDGEMENT  Social judgment: Good  Personal judgment: Good 3. FURTHER DIAGNOSTIC STUDIES  Physical examination: -  Neurological examination:-  Additional psychiatry diagnostic:-  Interview with family members, friends or neighbor:-  Psychological, neurological or laboratory test as indicated:- 4. SUMMARY OF FINDINGS/ RESUME Patient has had previous psychiatric condition starting late 1996. She was in duration of untreated illness for about 1 year. She was referred to HTF in 1997 because she develop the symptoms of agoraphobia, depressed, insomnia, labile mood, loss of appetite, headache, and lethargic. She also suffers auditory and visual hallucination. She claim that she had grandiosity delusion in her age of 14. After the born of her 1st child (2004) she had attempt a suicide by taking overdose medication and again she commit suicide when she was pregnant her 2nd child (2008). She feels worthless and hopeless at that time and her husband is living in Kuala Lumpur. Currently she still under her medication from her illness and came to HTF later today because she feel lethargic, restless, sleepy and unhappy with her life. 5. DIAGNOSIS  AXIS I : Schizophrenia Paranoid Type  AXIS II : Introvert Personality  AXIS III: None  AXIS IV: Problems with living condition, family problems of husband, eldest sister and have to take care of her parent as well, workplace problems especially with colleagues.  AXIS V: GAF 71-80
  12. 12. 12 6. DIFFERENTIAL DIAGNOSIS a. Schizoaffective Disorder b. Bipolar disorder 7. PROGNOSIS FACTORS GOOD POOR FAMILY HISTORY Elder sister with schizophrenia COMPLIANCE Good ONSET Insidious and early onset (<20) SUPPORT Good family support ECONOMIC Working MARITAL STATUS Polygamy married SYMPTOM Depression GENDER Female COPING WITH STRESS Poor PREDOMINANT SYMPTOMS Negative DURATION Long Overall prognosis is poor. 8. TREATMENT PLAN  Non Pharmacological : o Psychoeducation for the patient and family o Family therapy o Individual psychotherapy  Pharmacological: o Risperidone (0.5 – 8 mg) per day

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