Case ConferenceDepression

PREPARED BY
WOO WING JUN
ELICIA CHIENG

Patients Particulars
Mr

29

year-old malay male

Works

as auditor in HSBC bank

Married

for 3 years with no children

Chief Complaint
The

patient was brought in to the

emergency department by the father
and presented with suicidal attempt by
paracetamol overdosing of 10 tablets at
one go on 18/11/2015.

What would you ask next?

History of Presenting Illness

The wife requested for a divorce after his mother-in-law

passed away on the 1st October 2015 ( 2 weeks ago)

The wifes family blamed him for the death

Previously, the mother-in-law had undergone renal transplant

in HKL in April 2015, but the patient was unable to pick her up
upon discharge because his car was sent for service.

wifes family were not happy with him

Was informed that his mother-in-law was in critical condition

the day before her death, immediately booked tickets with his
wife back to Miri. Able to see his mother-in-law before her
death at 1.30pm, on 1/10/2015.

HOPI (continued)

At the funeral, the father-in-law suddenly shouted in front of

the relatives and accusing him for causing his mother-in-law
death

The wife changed the return tickets to the next

Saturday(10th October) without notifying him, she insisted
she will bear the extra charges on her own.

At the same time, the patient was tensed up with the

urgent job in KL because his boss claimed that he would be
reported to the Human resource department.

He ended up getting a warning letter from the HR

department after he was back to KL on the Saturday.

What are the symptoms you

would like to elicit from the
patient?

HOPI (continued)
For

the past 1 month,

felt

depressed and disappointed

vaped

up to one bottle per day which he usually finished in 2

weeks
had

loss of interest in the things he used to do such as swimming,

bowling

couldnt

concentrate and had poor attention at work leading to

poor performance of work, his boss started to pick on him

frequently
difficulty

absent from work

initiating sleep as he was preoccupied by his wife

 Sleeps

at 11pm, and frequently wakes up in the middle of

night at 1am, 3am and 4am,felt weak and experienced
headache in the morning the other day

loss

of appetite

waist

circumference reduced from 46 inch to 38 inch, and

Tshirt size from XXXL to XL

once

suicidal ideation by jumping into the swimming pool

no

auditory hallucination

no

manic or hypomanic symptoms

Past psychiatry history

He

was seen in the psychiatry clinic in 2011

for low mood after problems with his girlfriend
who is now his wife.

He

wasnt given any medication that time.

Past medical history

patient

had asthma, and last attack was at the

age of 17

mid

hypertensive and not on any antihypertensive medication

had

done extracorporeal shock wave

lithotripsy (ESWL) for removal of kidney stone
in 2014

urinary

tract infection within 2015

Family History

Both the parents are in 70s

Eldest brother is 47,married with 4

children, works as engineer

Second brother is 41 with intellectual

disability with psychosis

Third brother is 36, works as engineer

and married with 4 children

Sister is 31, works as doctor in Miri,

married with 2 children

Relationship with family members is

good.

Otherwise, no other psychiatry

illness,suicide in the family

Personal History

Perinatal history was unable to be elicited

childhood obesity and asthma

Average student, science stream

active in sport such as taekwando, bowling and

swimming

further his study in Degree of Accounting at UNITEN,

and subsequently took ACCA in gold coast, Australia

many close friends from the school

No major disciplinary problems

 worked

in hotel SPA for 2 months in Bahau

after back from Australia, his mum asked him
to back to KL.

So,

started working in AIG for 3 months

HSBC

bank since 2008 until now

Love marriage, married for 3 years with no children

Wife is studying quantity surveying

Frequently argue over small matters

wife had asked for divorce due to marital discord over

the past 1 month

Financial constraint, earn 3k a month with car loan,

house loan, and credit card debts

No criminal record noted

took alcohol (Heineken) on weekly basis when he was

in UNITEN, average 3 big bottles each time

Stopped after back to Malaysia

denied cigarette smoking

However, he vaped every day, and used to finish one

bottle in 2 weeks, but has been finishing a bottle each
day

No substance or illicit drug use

Premorbid Personality

hot-tempered person

sometimes likes to be alone

likes to go on vacation

vapes or heads to gym when he is stressful

Mental State Examination

General

appearance

well-groomed

malay male dressed in hospital attire

Unshaven,

messy hair

Conscious

and forthcoming

maintained

good rapport and eye contact but at times, he

distracted by surrounding people

no

abnormal movement noted

Speech

and thought

Speech

is coherent and relevant with normal amount, tone

and rate

Has

suicidal thought (jumping into pool or fire)

 Mood

and Affect

Mood

is euthymic and was congruent to the affect

Perception
no

hallucination (but he reports hearing voices

asking to kill himself when he felt depressed in the
ward)

No

illusion, flashbacks, depersonalization, and

derealization

Cognitive function
Orientation
disorientated

to time, place and person

Memory
remote
Able

and recent memory were intact

to recall 3 out of 5 words in the 5 minute work

test
Information

and Vocabulary

appropriate

to his age, education level and

sociocultural background

 Abstraction
able

to tell the similarities between apple and orange

in abstract manner

Attention

and concentration

couldnt

perform serial 7 test but he managed to

count digit span and spell world backward

Judgement
impaired

as he would jump into fire when he saw a

building caught on a fire

Insight
Good

insight

Provisional diagnosis
Severe

Major depressive disorder with

psychosis

Differential Diagnosis
Prodrome

of schizophrenia

Schizoaffective
Bipolar

disorder

disorder in depressive phase

Investigation

Full blood count

Liver function test

Renal function test

Thyroid function test

ECG

Psychiatric Formulation

Aetiology
BIO
Predisposing
factors

PSYCHO
Dependent
personality
Pampered child
Hot-tempered

SOCIAL
Financial constraint
Frequent argument with
wife
Disliked by the wifes
family

Precipitating
factors

Divorcement
Difficulties in work

Perpetuating/
maintaining
factors

Unresolved marriage
problem

Management
BIO

Acute

Detoxification
Anti psychotics for
auditory hallucination
Anti depressants
(Escitalopram)
Admitting patient to
ward to monitor

Anti depressants
Electroconvulsive
therapy (if treatment
Long Term
resistant, high
suicidal risk)

PSYCHO

SOCIAL

Allow patient to vent or

speak out his problems

Family support

Cognitive behavioural
therapy
Psychodynamic therapy
Supportive
psychotherapy

Marriage counsellor
Social support from
family members

THANK YOU!
ANY QUESTIONS?