1.

History
Date of Clerking & Location of History & Examination: Male Ward, Hospital Hulu
Terengganu
a. Patients Personal Identification:
Name Mohd Nasri Bin Endut
Age 41 y/o
Gender Male
Marital status Divorce 2 years ago, blessed with 3 kids
Race Malay
Religion Islam
Occupation Labour
Address Dungun
Date of Admission 6 MAY 2017
Date of Clerking 11 May 2017 (5days after admission)
Source of History Patient himself & case file

b. Presenting Complaints:
Brought to ED in hospital Dungun by policeman and referred to HHT due to aggressive
behavior and verbally abusive towards his parents on the day of admission.

c. History of Presenting Complaint:

My patient has mental health illness for 2 year. He has history of involuntary
admission to HHT in 2015 as he is walking naked and trying to intrude female hostel.
In April 2015, after divorce with his wife, he denied of depressed mood and
claimed to be happy and energetic. He became more talkative and like to gossip with
strangers in caf shop. He claimed he had difficulty in falling asleep, and wake up early
and slept for 4 hours but he still felt energetic on the next day. Moreover, he go to PUB
frequently and found girls and claimed to have multiple safe sexual intercourse with the
girls. He planned to do online business such as on FB sell items like shoes, clothes and
towels but unable to achieve due to unstable financial status. He changes his job very
frequent because his employer was unhappy with his work performance such as came
late, go back early or lazy come for work. Otherwise, he denied of being controlled by
external force, mind been read by other people or can read people mind. He denied of
hearing voices and seeing unusual things, experiencing unusual physical contact and
perceiving abnormal smells or tastes.
The sx persisted until July 2015, my patient unable to sleep so he started to
wander around in the midnight and he was caught by security because he was walking
naked and he try to intrude into the female hostel. He was sent to HHT by policeman and
hospitalised for 1 weeks, he was discharged with medication and ECT was not done. He
took his medication under the supervised of his mother and go for regular follow up in
hospital Dungun, accompanied by his mother.
He was symptoms free upon discharge from the last admission until current admission. (2
years)
My patient is well until 2 months ago, he heard his ex-wife remarried to a young,
handsome rich Malay man. His mood became bad, felt unhappy and easily irritable. He
started to default follow up in Hospital Dungun and not compliance to medication.
Recent 2 months, he started to have a strong belief that he had a special gift from
Allah, which protected him from bad spirit even though he cannot see it but he can felt it.
He claimed he is head of police and his job is to catch criminal. For example, last time a
criminal drove a lorry and try to bump into him, he was protected by a shield surrounding
him and lorry was rebound. He said when he was stress, he will knock the wall with his
head, he was not injured but the wall was spoiled. Otherwise, he denied of being
controlled by external force, mind been read by other people or can read people mind. He
denied of hearing voices and seeing unusual things, experiencing unusual physical
contact and perceiving abnormal smells or tastes. He also denied experience of hearing
own thought or seeing figure behind his back.
My patient complained of having reduced in sleeping hours for the past 1month
prior admission. His usual sleeping hour is about 6 to 7 hours a day. However, he only
slept for 3 to 4 hours a day, telling that he slept at 1 a.m. and woke up at around 4 a.m. He
said I dont feel like sleeping at night and I felt energetic in the next morning even
though I slept for 3-4 hours.
Currently he worked as labour and his monthly income was RM1500. He planned
to buy a new car and wanted to open a shop selling rings, cloths and etc. to earn more
money because he also planned to marry a 20 y/o young pretty lady and her father
requested RM100, 000 for agreement of their marriage. He also spent most of his money
on treating girls in PUB and have sex with them. When he do not have money, he will
wandering around his house area and naked again.
On the day of admission , his parent do not allowed patient go outside in day and
night and he became angry, verbally abusive towards his parents and started to throw
items in house. He even chased his parent outside of the house and locked the door. His
parents was scared and immediately reported to police. Before being transferred to
psychiatric ward in HHT, he was given 5mg Haloperidol intramuscularly in the
emergency department. My patient was then non-irritable, manageable, cooperative and
able to sleep well. There was no aggressive behavior was noticed in the ward. Currently
he is on Risperidone 1mg BD and valproate 400mg bd.
Patient denied of depressive symptoms such as feeling depressed, sad,
worthlessness, guilt, poor appetite, reduced in interest to surrounding, or having any
suicidal thoughts. Besides that, patient denied of any anxiety symptoms such as
palpitation, fear, shortness of breath, chest pain, excessive sweating and fear of dying.
He denied of substance abuse and somatic symptoms such as fever, headache,
blurred vision, abnormal movements, loss of consciousness, nausea and vomiting and
changes in bowel or bladder habit.

Systemic Review - unremarkable

Cardiovascular System: No chest pain, palpitation and perfuse sweating
Respiratory System: No cough, haemoptysis, dyspnoea or coryzal-like symptoms.
Gastrointestinal System: No abdominal pain, nausea, vomiting, diarrhoea, constipation or
bloody stool.
Genitourinary System: Normal urination and colour, no frequency, urgency or
haematuria.
Nervous System: No headache, dizziness, syncopal attacks, fitting episodes or blurring of
vision.
Musculoskeletal System: No muscle or joint ache, weakness, stiffness or low back pain.
Past Psychiatry History
 1st admission, 1 weeks hospitalization, ECT not done, sodium valproate
medication. (July 2015)
Side effect of drug
Valproate 200mg BD weight gain, GI upset, sedation, tremor,
thrombocytopenia and raised liver enzymes.
May 2017 Current admission, ECT not planned
on ED, haloperidol and midazolam, IM, 10mg
Currently he is on Risperidone 1mg BD and valproate 400mg bd.

Past Medical History/ Past Surgical History

No previous medical illness such as epilepsy, thyroid disease, heart disease, brain
lesion, seizures, diabetes, hypertension or asthma.
No surgery done before.
Drug History
Currently he is on Risperidone 1mg BD and valproate 400mg bd.

No traditional medicines or supplements.

No known drug or food allergies.

Family History
Currently his mother is 65 years old and stepfather father is 70 years old.

He is the eldest among 10 siblings.

Patients biological father die when he was 8 years old due to stroke. His mother
remarried when he was 10years old, his stepfather is a kind, generous and helpful Malay
man who worked as government servant. He claimed to have good relationship with
family who is supportive to him.
There are no known mental illnesses in the family.
No family history of substance use and suicidal thought.

Personal History
 Birth History Patient was born via full term spontaneous vaginal delivery. There
were no known birth complications or birth defects.

Childhood History His development was normal with complete vaccinations and
denied of any complications during the birth process. His childhood period was
good and no history of childhood abuse.

Schooling History Patient is enjoy going to school. He entered school at the age
of 7 and studied until Form 5. He claimed he not interested in study and his SPM
result all fail.

Occupational History: After SPM, he worked as waiter for 5 years in a coffee

shop and worked as lorry driver for 17 years until he had mental illness. Since
then he frequently change his works as mention in HOPI.

Adolescent History He claimed to have many friends. He used to hang out with
them in the late evenings, playing badminton and jogging. He took on smoking
since 18 years old but did not use any drugs or drink alcohol.

Relationship History: Patient had married his wife for 15 years.

After divorce (2015 April), 3 children stay with ex-wife (11, 8, 5). Claimed to
have multiple sexual partner recent 2 months.
His diet is healthy with 3 meals a day consisting of rice, vegetables and meat with
occasional fruits.

Social History
He is currently living with his parents in a village house in Dungun. Currently, his
income is stable because he is working.

Forensic History
No substance abuse or criminal record.
Premorbid Personality
Prior to the illness, he was an outspoken, friendly, easygoing person who enjoyed his life
and work. He enjoyed attending social events and meeting new people. He liked to spend
his time to hang out with friend in the coffee shops chitchatting and play badminton. His
faith in religion was strong and he was usually a relaxed person with normal mood most
of the days.
Mental Status Examination
1. Appearance and Behavior
Patient appeared to be an early 40s gentleman which was appropriate to his actual age.
He has moderate built and nourishment seemed to be fair. He was wearing hospital attire
with good hygiene. Good eye contact during the interview, facial expression and body
language were appropriate. Throughout interview, patient seems excited and happy to
answer every questions. Theres no psychomotor agitation or retardation. There were no
abnormal movements or abnormal postures. No abnormal behavior, posture or
movements such as stereotypy or mannerism observed. No physical signs of anxiety such
as sweating of hands and tremor. No depressive signs such as tearful eyes, downcast.
Patient was very cooperative and rapport was easily built.
2. Speech
He is talkative. He talked fluently in Bahasa Melayu with increase amount and volume.
The tone of his speech was normal. There is pressure speech. No poverty of speech. His
speech was relevant and coherent.
3. Mood and Affect
He described his mood as happy for the past 2 weeks. His affect was broad in range but
not labile. His affect was congruent with mood.

4. Perceptual Disturbances
No hallucination, illusion, derealization and depersonalization.
5. Thought Disturbances
Process
He has flight of ideas but no loosening of association, no neologism, no tangentiality and
no circumstantiality.
Flow
There was pressured of thought but no thought blocking or poverty of thought noted.
Content
Still have Delusion of as grandiosity. There are no suicidal ideation and homicide
thought.
Possession
There were no thought insertion, no thought withdrawal and no thought broadcasting.
6. Cognition
Orientation
He was conscious and orientated to time, place and person.
Attention & Concentration
He was able to count days forwards and backwards.
Memory
His immediate memory was good as he was able to recall objects that were told to
remember a minute ago. His recent memory was good as he was able to recall what he
had breakfast. His remote memory was good as he was able to recall his IC number and
date of Malaysias Independence Day.
Information and intellectual
He has good comprehension, general knowledge, calculation and vocabulary. He was
able to tell the name of Malaysias Prime Minister and the First Lady of Malaysia.
Abstract thinking
He has good abstract thinking. He was able to explain the proverb bagai aur dengan
tebing correctly. He was able to identify similarity between cats and dogs; and the
difference between table and apple.
7. Judgment
Social judgment was good as he thinks that throw items in house and chasing his parent
out of house is wrong.
Test judgment was good as he knows that he needs to call the fire brigade when there is a
house on fire.
Personal judgment was good as he told that he will open an online shoes shop on
facebook to earn money.
8. Insight
He has good insight as he accepts his mental illness and understands importance of good
compliance to medication in order to control his symptoms.
Physical Examination
a. General Appearance:
My patient was sitting comfortably on a bench with adequate nutrition and hydration
status. He was not in any form of distress. He is moderately built up with BMI of 26.7
kg/m2.( Overweight)
Height: 1.56 m
Weight: 65kg
b. Vital Signs:

Pulse rate 80 beats per minute, regular rhythm

and normal volume
Breathing rate 16 breaths per minute (Normal)
Body temperature 37 C (Afebrile)
Blood pressure 110/75 mmHg (Normotensive)
Pain score 0 out of 10 (not in pain)

c. Extremities:
Hand Legs
His hands were pink and warm. No palmar erythema, Normal skin. No ankle
sweating, pallor, leuconychia, koilonychia, finger swelling.
clubbing, peripheral cyanosis or flapping tremor.
Capillary refill time was less than 2 seconds. Needle
tracks were absent.
d. HEENT:
Head There was no face and neck spasms noted.
Eyes No conjunctival pallor. No jaundice. Pupils were equal and appropriate in
 size of around 4mm bilaterally. There was no lid retraction, exophthalmos
or other signs of hyperthyroidism.
Ear Hearing was normal on both ears. Examination with otoscope was not
performed.
Nose No nasal discharge and nasal blockage.
Throat Oral hygiene was adequate. No central cyanosis. No oral ulcer. No spasm
of tongue.

e. Systemic examination
Neurological examination
Gastrointestinal system examination
Respiratory examination
Cardiovascular system examination
Musculoskeletal examination
Cranial nerves are intact. Sensory
function, motor function and coordination
are normal.
No abdominal tenderness. Abdomen is
not distended. No palpable mass and
hepatosplenomegaly. Kidneys were not
ballotable. Normal bowel sounds and no
bruit heard.
No palpable lymph nodes were
appreciated over neck. Normal chest
expansion. Normal vesicular breath
sounds heard without added sounds.
No thrill and heave. Normal heart sounds
heard without added sounds and murmur.
Normal joint function. No abnormal gait
and posture. No tenderness elicited. No
swelling. No deformity. No muscle
wasting.

Summary
My patient has mental health illness for 2 year. He has history of involuntary admission
to HHT in 2015. He was symptoms free for 2 years since last discharge from HHT.
Currently, he is under hospital Dungun follow up, defaulted and not compliance to
medication since 2 months ago. After hearing her wife remarried, he became easy
irritable, talkative, felt energetic despite of insomnia, have grandiosity, spending spree,
increased goal-directed activities and increased sexual activity for recent 2 months. There
is no family history of mental illness. He had good family support and good premorbid
personality. Physical examination was unremarkable except BMI 26.7(weight gain). In
mental status examination, he is talkative with pressure speech, unable to interrupt,
increase amount and volume. His speech was relevant and coherent. His mood as happy
for the past 2 weeks. His affect was broad in range but not labile. His affect was
congruent with mood. No perceptual disturbances. Thought process: he has flight of
ideas and pressured thought. Content still have Delusion of as grandiosity. His
cognition was also intact. His social, test and personal judgment were good. His insight
was good. Otherwise, there is no history of substance use, any underlying medical
conditions or any trauma.

5.1. Provisional diagnosis

Bipolar 1 disorder in manic phase with mood congruent psychotic feature
Points for Points against
Persistently irritable mood for past 2 months. None
5 out of 7 manic symptoms (increased in goal directed activity,
delusion of grandiosity, reduced need of sleep, talkative than
usual and involvement in sexual indiscretion)
No history and examination suggestive of substance abuse or
underlying medical conditions

5.2. Differential diagnosis

1. Bipolar Disorder due to another medical condition
Points for Points against
Late onset of clinical picture of No evidence from the history,
bipolar disorder physical examination that suggestive
of any medical illness
2. Substance-induced bipolar disorder
Points for
Presence of mood symptoms and
patient may not be disclosing the
truth.
Points against
Patient deny. No evidence from the
history, physical examination that
suggestive of substance abuse.

3. Schizoaffective disorder
Points for Points against
Late onset of clinical picture of No evidence from the history,
bipolar disorder physical examination that suggestive
of any medical illness
6. Investigations
Biological investigation
1. Full blood count
baseline investigation before treatment initiation

monitor for thrombocytopenia as a side effect of sodium valproate

to rule out medical illness such as malignancy

2. Renal function test

Baseline investigation before treatment initiation

3. Thyroid function test

To rule out hyperthyroidism which can presented with manic episode

4. Liver function test

Baseline investigation before starting medications as most of the psychiatric

medications are metabolized in liver

To monitor side effects of sodium valproate which can cause liver function
impairment
5. Fasting blood glucose, lipid profile, microalbumin test and regular blood pressure
and BMI monitoring

Baseline investigation to rule out metabolic syndrome which is a side effect of

atypical antipsychotic.

6. Urine toxicology screening

To rule of substance-induced bipolar disorder

7. Brain imaging (CT scan or MRI)

To rule out neurological disorder which may give rise to manic episode such as
multiple sclerosis

8. Syphilis, HIV, hepatitis B and C screening

Patient have multiple sexual partners.

Psychosocial investigation
Interviewing his family to obtain a complete picture of his pre-morbid personality,
current symptoms and condition

Tracing his old medical records and case sheets to look at the progression of the
illness and also the medication he took.

7. Management
Principle of management:
Assessment and early treatment

Plan for psychosocial intervention

Dealing with treatment adherence issues

Addressing potential risk to self and others

Monitoring
 Management for special population

Admission criteria:
Risk of suicide or homicide

Reduced ability to get food and shelter

Diagnostic procedure

Rapidly progressing symptoms

Rupture of usual support system

a. Biological treatment
Biological treatment can be divided into acute and maintenance phases. Selection of
medications are based on considerations including concomitant medications, previous
medication response and family history of medication response, side effects, patient
preferences, as well as medical and psychiatric comorbidities.
Acute phase treatment of mania
Mood stabilisers or antipsychotics, either as monotherapy or combination, should be used
to treat acute mania in bipolar disorder. According to Malaysias CPG on management of
bipolar disorder in adult, lithium is considered as the gold standard of treatment for acute
mania. However, lithium, valproate and carbamazepine are equally efficacious in acute
mania. Additionally, benzodiazepines may be used during acute mania.

Types of medications Name of medications

1. Mood stabilisers Lithium, valproate and carbamazepine
2. Typical antipsychotic Haloperidol
3. Atypical antipsychotic Risperidone, olanzapine, ziprosidone,
asenapine, quetiapine, paliperidone and
aripiprazole

The dose range and main adverse effects of medications are shown in Appendix 6.
Algorithm 2 shows management of acute mania.