FACULTY OF MEDICINE

Case Write Up
MBBS Year 3 Term 2
(April/May Intake 2016)
Academic Year 2018 – 2019

Name of Student Tan Qi Wen

Matric Number BMD 2016/040235

(QIUP-201605-001901)
Name of Subject Psychological & Behavioural
Medicine
Coordinators Prof. Dato’ Dr. N. Raman
ASP Dr Bilbir Kaur
ASP Dr Eddie Soon Cheng Kung
Hospital Hospital Bahagia Ulu Kinta
Patient’s Profile:
Name : Burhanuddin Bin Harun
Age : 66 years old
Gender : Male
Ethnicity : Malay
Address : 47, Lorong Dua, Kg Semangat Titi Gantung Bota Kiri 32600 Bota,
Perak
Date of admission : 13 January 2019
Date of clerking : 15 January 2019
Date of discharge : (Transferred to Male Inner Ward on 17 January 2019)

Main Complaint(s) / Reason for Referral:

Auditory hallucination for the past 2 months causing him to have sleep disturbance

History of Presenting Illness:

According to patient, he was apparently well until 2 months prior to his admission in
WKL in Hospital Bahagia Ulu Kinta (HBUK) for second person auditory hallucination. He
was brought by his 70 years old uncle from home 2 days ago, with admission under
BORANG 1.
Patient complained that he heard only a female voice, which the voice was talking
directly to him, telling him to ‘hit his uncle’ repetitively but patient denied that he has
followed the voice. It has happened on and off spontaneously throughout the past 2 months,
especially during the midnight. He will hear the voice while he was on bed sleeping in the
same room with his grandchild, but patient was still in a fairly conscious state as he could not
fall asleep because of the disturbance from the voice, making him quite agitated from time to
time. Therefore, patient will take sleeping pills and he claimed that the voice will disappear
after intake. He usually will start to sleep at 1 a.m. with duration for about 6 hours, but he felt
not refreshed and less energetic after woke up from sleep. It was associated with visual
hallucination for the past 2 months. He complained that he could see a shadow that looked
like a ghost, especially during the midnight while he was not asleep. He will try to scold the
shadow, and claimed that it will disappear afterwards. Throughout the period he did not seek
for help. Otherwise, no other hallucinations were identified such as olfactory, gustatory, or
tactile.
There is persecutory delusion, as he feels that his family especially his wife and
children dislike him because of his current condition. There is delusion of jealousy, in which
he feels that there are widows or ‘janda’ who are jealous of his property as he is an ex-
military. Otherwise, no delusions of control, reference, grandiose, somatic, erotomania, or
guilt are identified.
He has loss of appetite and reduced weight from 70+ kg to 60+ kg within the past 2
months. Sometimes, he will feel tension as his wife will nag at him on going out during the
daytime frequently, suspecting of taking ‘air ketum’, but patient denies of it. For the past 1
month, he starts to get depressed as he thinks that his family members dislike him due to his
current condition; however, he does not feel hopelessness, lack of drive, or loss of interest,
and he denies of having any suicidal ideation or attempts. Otherwise, there are no manic or
hypomanic episodes throughout the period.

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Past Psychiatric History:
This is his 27th hospitalisation. He has multiple hospitalisations in hospitals such as Hospital
Perak Road in Penang, Hospital Kinrara in Kuala Lumpur, Hospital Angkatan Tentera Kem
Terendak, Malacca, and HBUK. He was unsure of his 1st hospitalisation but it was around the
time while he was still a military. His last admission was on August 2018 in HBUK for about
2 weeks because of the similar complaint. He has his follow-up in KK Bota Kiri monthly
once, with intramuscular injection Clopixol depot 400 mg monthly given for his mental
illness. He was given oral medications, which are Risperidone 2 mg ON along with Artane 2
mg ON. He was unsure of his compliance.

Past Medical / Surgical History:

Patient is known to have hypertension since 2 to 3 years ago with on-going oral
antihypertensive Amlodipine 10 mg medication. He also had a motor vehicle accident at Kg
Jering since 2 years ago which required 3 days hospitalization in normal ward with CT scan
was done, but declared to have only mild head trauma without complications.

Family History:
Both the patient’s parents have passed away due to old age when they are at 70+ years old.
He is the 3rd child among the 7 siblings in his family, but his eldest brother passed away at 37
years old due to motor vehicle accident, and his youngest brother died at 45 years old due to
murder. Otherwise, there is no known mental or medical illness in his family.

Personal History:
Birth : Born at home with uncomplicated spontaneous vaginal delivery
Development : No known serious childhood illness, trauma or developmental delay
Education : Studied until Standard 6 in primary school due to poor financial status
Occupation : Serviced as military in Regimen Askar Melayu Diraja in Pahang for 10 years
: Worked at Department of Irrigation and Drainage in Teluk Intan for 4 years
: Worked at a palm oil factory managing water irrigation and drainage for 10
to 12 years.
: Currently he is unemployed but with pension.
Marriage : Married in year 1982 (37 years). His wife is currently 58 years old
They have 4 children in total. No known medical or mental illness, except the
eldest child passed away at 37 years old due to heart disease
Sexual : No recent sexual intercourse with wife, but patient claimed to masturbate
monthly once. No sexual promiscuity.
Drug/ : Admit to have only ‘air ketum’ since long ago, but denies recent usage of it.
Substance use Active smoker since 17 years old, 10 cigarettes per day, 24.5 pack-years
of smoking

Premorbid Personality:
Patient was an active energetic young man who likes to socialize and interacts with people.

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MENTAL STATE EXAMINATION:
Appearance & Behaviour:
An elderly man with average body built in hospital attire sitting comfortably. He appears to
be alert and conscious, clean, calm, good eye contact, with resting tremor of his left hand.

Speech:
Patient is forthcoming and speaks in Malay language in a normal rate with adequate volume.
He speaks coherently and answers in relevant to the questions given. No neologism,
circumstantial or tangential speech identified.

Mood & Affect:

Patient is feeling calm and normal at the moment. His mood is appropriate and euthymic; and
affect is normal.

Perceptual Disorders:
No illusions identified. No hallucinations at the moment such as auditory and visual
hallucinations.

Thought Procession & Contents:

No flight of ideas or looseness of associations. No delusions at the moment. No
preoccupation, phobias, overvalued ideas, suicidal ideation, or obsessive compulsive
behaviour. No thought insertion, thought withdrawal, or thought block identified.

Cognition:
Orientation : Not impaired. He could answer time, place, and person correctly.
Memory : Not impaired. He could recall immediate, recent and remote memories.
Attention & : Fairly good. He could answer the serial 7’s test accordingly.
Concentration
Abstraction : Fairly good. He could roughly define the meaning of proverbs and
explain the similarities between 2 objects given.
General knowledge : Fairly good.
Judgement : Not impaired. He could give appropriate answers with the given
scenarios such as neighbour’s house on fire and an envelope dropped
on the road.

Insight:
He has a fairly good insight on his current condition. However, he could not exactly explain
his mental illness at the moment. He could understand the importance of having compliance
of his medication, as well as follow the medical professional’s prescription and advice in
order to get his illness well-controlled for him to attain a better quality of life.

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PHYSICAL EXAMINATION:
General Examination:
An alert and conscious elderly man on hospital attire with an average body built, cooperative,
sitting comfortably in a chair. He is fairly pink with fair hydration status. On examination, he
has palmar erythema with nicotine stains on his fingers, and notices resting tremor at his left
hand. He has corneal arcus noticed while on head examination. Otherwise, there are no signs
of clubbing, anaemia, jaundice, lymphadenopathy, peripheral and central cyanosis.

Vital signs:
Temperature : 37°C
Pulse rate : 84 beats/ minute (regular rhythm, normal volume)
Respiratory rate : 20 breaths/ minute
Blood pressure : 134/ 88 mmHg

Systemic Examination:
Cardiovascular : Normal 1st and 2nd heart sounds, no murmurs
Respiratory : Equal air entry, clear lung fields, no rhonchi, crepitation, pleural rub
Abdomen : Soft and not tender, no hepatosplenomegaly
Central Nervous : Sensory & motor examination, cranial nerve examination, higher
System cerebellar examination are grossly intact

Provisional Diagnosis:
SCHIZOPHRENIA
Points for:
i. Auditory hallucination
ii. Visual hallucination
iii. Delusions of persecution, jealousy
iv. History of multiple hospitalisations of similar complaints in psychiatry ward, on
antipsychotic medication
v. History of substance abuse, intake of ‘air ketum’ which may deteriorate his mental
condition causing relapse of his disease

Differential Diagnosis:
SUBSTANCE-INDUCED PSYCHOSIS
Points for:
i. Auditory hallucination
ii. Visual hallucination
iii. Delusion of persecution, jealousy
iv. History of substance abuse, intake of ‘air ketum’

SCHIZOPHRENIFORM DISORDER
Points for:
Auditory and visual hallucination of 2 months duration with delusions of persecution and
jealousy, if excludes the patient’s past psychiatric history of multiple hospitalisations.

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Identifying Patient’s Problems in Order of Priority:
Patient may have issue in taking care of himself due to the mental illness and he is now
currently senile which may lead him to have reduced self-care capability, in which it may
cause him to have relapse from his long-term mental illness known as Schizophrenia. In
addition, patient is suspected to have abuse of ‘air ketum’ which is usually available in the
village, which may be another factor in contributing to his relapse of mental illness.
Therefore, in his case, compliance to medication, psycho-education, social rehabilitation as
well as family support is important in preventing his disease from relapse and to improve his
quality of life.

DISCUSSION:
Schizophrenia is a serious mental illness characterized by psychotic symptoms such as
delusions and hallucinations. According to DSM-5, to diagnose Schizophrenia there must be
at least 2 or more of the following symptoms, with each present for a significant portion of
time during a 1 month period (or less if successfully treated). At least one of these must be
delusions, hallucinations, or disorganized speech, either with or without the presence of
catatonic behaviour or negative symptoms, and the disturbance is not attributable to the
physiological effects of a substance (e.g. drug abuse or medication) or another medical
condition. In Schizophrenia, the patient suffers from psychotic symptoms and functional
impairment. It could be a particularly disabling illness because its course, although variable,
is frequently chronic and relapsing. The care of patients with schizophrenia places a
considerable burden of all carers, from the patient’s family through to the health and social
services. Therefore, a full assessment is crucial in recognising the basic symptoms of
Schizophrenia, and management of these patients must be of bio-psycho-social approach in
order to provide them an early and effective intervention as quickly as possible after the onset
of symptoms. Family support is important in the involvement of managing patient’s well-
being, as awareness and knowledge has to be conveyed to them in which recognising early
warning signs of relapse could be greatly useful in allowing early intervention and proper
care for patient to get improved from his illness without great impairment on their quality of
life and function.

INVESTIGATIONS:
Full blood count – check for red blood cells and haemoglobin to rule out anaemia, white
blood cells to rule out infection, and platelet count for assessing haemostatic factors
Renal profile – to assess renal function and to rule out dehydration
Liver function test – to assess liver function and to rule out underlying liver diseases related
to infection or substance abuse (e.g. alcohol)
Fasting lipid profile – to assess various lipid and cholesterol levels and to rule out
dyslipidaemia
Fasting blood glucose – to assess blood glucose level and to rule out hyperglycaemia or
diabetes mellitus
Urine dipstick and urine drug test – to rule out drug or substance usage
ECG – to assess for cardiac function by monitoring the cardiac rhythm and conduction of
electrical impulse, and to rule out underlying cardiac diseases

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MANAGEMENT:
1. Admit patient.
2. Apply bio-psycho-social approach to manage patient’s well-being.
a. Biological:
 Antipsychotics (T. Risperidone 2 mg ON, IM Clopixol depot 400 mg monthly)
 Anticholinergic (T. Artane 2 mg ON)
 Antihypertensive (T. Amlodipine 10 mg OM)
b. Psychological:
 Psycho-education, family counselling on the diagnosis, importance of medication,
side effects of medication, and adherence of medication, early warning signs of
relapse, lifestyle modification, etc.
c. Social:
 Rehabilitation + occupational therapy

PROGNOSIS:
Fairly good; patient exhibits positive symptoms which may be easily identified at earlier
phase of disease onset. Although he has multiple hospitalisations due to his psychiatric illness,
but patient has good premorbid social, sexual, and work histories with a good marriage life.
He has a fair family support and no history of psychiatry illness identified in his family.
Patient understands the impact of his mental illness to his life and he has a strong wish to
prevent it from relapse by compliance on medication and regular follow-up in order to
maintain his well-being and by improving his quality of life and avoid from practicing bad
activities that may deteriorate his condition.