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

1

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.

2

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.

3

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.

4

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

5

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

6

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.

7

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.

8

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 :-

9

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.

10

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 1 st 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

6. DIFFERENTIAL DIAGNOSIS

11

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

12