Identification Data

Mr T is a 19 years old indian boy with known comorbid of bronchial asthma. He is a student in Diploma of automative, single, live in Ipoh with his mother and siblings.

Reason for admission

Mr T was brought by his mother because she afraid he might harm himself

Chief complaint

Mr T came to casualty because his mother afraid he might harm himself due to stress for 2 days prior to admission

History of presenting illness

On 15th July 2014 which was 9 days ago, Mr T had a quarrelled with his girlfriend because he felt that her behaviour had changed after she went to further her study in Kuala Lumpur. He felt that she was cheating on him because he found out that she had social apps such as WeChat and Whatsapp. However, his girlfriend claimed that it was a fake account. Mr T told that when he entered his girlfriends phone number, her profile was shown up in the social apps. He also claimed that his girlfriend was cheating on him because she was not answering his call. He also had 2nd person auditory hallucination which started 1 day prior to admission and it was the first episode. There was 1 male and 1 female voice. It was commanding in nature. The voices asked him to cut his hand and always told that his girlfriend was cheating on him. The auditory hallucination lasted for 1 hour which occured in the morning. However, he did not have suicidal ideation. He denied presence of delusion. He claimed that he had difficulty to fall asleep and had an early awakening since he had a problem with his girlfriend in January. He slept for 2 hours but when he woke up, he felt he had slept for a long period of time. He also had loss of appetite and loss of weight. Since he met his girlfriend, he had lost 4 kg. He had no anhedonia, feeling of worthlessness, energy deficit, concentration deficit, flight of ideas, distractibility and inflated self-esteem.

Family History

His father had passed away last year at the age of 54 years old due to ischaemic heart disease. His mother is alive and well. He is the third out of 5 siblings. His elder brother had epilepsy while his other siblings are alive and no medical problem. He has no family history of mental illness.

13 year old

17 year old

20 year old

Epilepsy

21 year old

Personal History

Mr T had a close relationship with his father. Since his father had passed away one year ago, he worried that he wont be loved again. He claimed that his mother is not loving towards him and will only heard Mr Ts problem when she is in good mood. He claimed that his mother always beat him and his siblings always isolated him. He also had poor relationship with his friends. His friends always tried to avoid him if he asked his friends to lepak with him. He spent most of his time focusing on his girlfriend. Mr T claimed that he is a person who always do all the work by himself. He will solved his problem by himself and rarely asking help from his family or friends.

Academic Record

He started school at the age of 7 years old and left school at the age of 17 years old. He claimed that he was an athlete for his school. For UPSR examination, he only remembered that he got 1A. As for PMR, he forgot the results but he claimed that he passed the PMR. For SPM, he failed because of lack of concentration but there was no family or girlfriend issues at that time. He claimed that he mixed with all the students and he did not have problem with his friends. He had a best friend named, Kamal who is now in Jitra pursuing his studies in automotive. He denied school truancy.

Work record

He started working as a promoter in The Stores on 18th June 2014. However, his employer fired him because he always did not come to work and not punctual. He claimed that he did not go to work because he had problems with his girlfriend which cause him to lose concentration in everything he did. He was involved in an accident because of the problem with his girlfriend

Past Medical History

No past medical history

Past Psychiatric History

This is the first time he was admitted into Ward 24. Previously on 9th June 2014, he cut himself on the left forearm because he was depressed that his girlfriend was ignoring him. Then, he went to Klinik Kesihatan Gunung Rapat to seek for treatment. Klinik Kesihatan Gunung Rapat referred him to Dr Selvaraju for further treatment and counselling.

Mental Status Examination

General Appearance and Behaviour

He was in a hospital attire. He was in good hygiene and well-kempt. He had good eye contact, cooperative and had a good manner.

Speech

His speech was relevant and coherent

Mood

Euthymic

Affect

Broad and appropriate affect

Thought content

No delusion and suicidal thought

Perceptual disturbance

No auditory hallucination and illusions

Sensorium and Cognition

a) Consciousness : Alert

b) Orientation : He was orientated to time place and person

c) Attention and concentration : He able to spell WORLD backwards

d) Memory :

a. Immediate: Able to tell back the 5 items after 5 minutes

b. Recent: He able tom remember the day he was admitted

c. Remote: He knew who is the winner of the World Cup 2010

e) Fund of knowledge: He knew who is the Prime Minister of Malaysia

f) Abstract: He knew what is bagai aur dengan tebing

Judgement

Insight

Good insight