Identification DataName:Mr T

Age:19 years old

Sex:Male

Education:Diploma in Automative

Occupation:Student

Marital Status:Single

Race:Indian

Religion:Hindu

Address:8 Laluan 10, Taman Seri Ampang, 31350 Ipoh, Perak

Date and time of admission:17/7/2014 21:20:27

Registration Number:HRPB211906

Chief complaintMr T came to casualty because his mother afraid he might harm himself due to stress for 2 days prior to admissionHistory of presenting illnessOn 15th July 2014 which was one week 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. That was the reason why he felt she was cheating on him.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 occurred 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. Past Psychiatric HistoryThis 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 counsellingPast Medical HistoryNo past medical historyPast Surgical HistoryNo past surgical historyFamily HistoryHis father had passed away in June 2013 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. His mother, eldest sister and himself went to work to support the family.Ischaemic heart disease13 year old17 year old20 year old

Epilepsy21 year old

Personal HistoryMr T was unable to remember his developmental milestone.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 hang out with him. He spent most of his time focusing on his girlfriend.

Academic RecordHe 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 were 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 recordHe 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. However, he did not sustain any head injury during the accident.Drug and Alcohol UseMr. T denied using drugs or substances. He also denied taking alcohol.Premorbid personalityMr 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.Mental Status ExaminationGeneral Appearance and BehaviourHe was in hospital attire. He was in good hygiene and well-kempt. He had good eye contact, cooperative and had a good manner.SpeechHis speech was relevant and coherentMoodEuthymicAffectBroad and appropriate affectThought contentNo delusion and suicidal thoughtPerceptual disturbanceNo auditory hallucination and illusionsSensorium and Cognitiona) Consciousness : Alert and consciousb) Orientation : He was orientated to time place and personc) Attention and concentration : He able to spell WORLD backwardsd) Memory : a. Immediate: Able to tell back the 5 items after 5 minutesb. Recent: He able to remember the day he was admittedc. Remote: He knew who is the winner of the World Cup 2010e) Fund of knowledge: He knew who is the Prime Minister of Malaysiaf) Abstract: He knew what is bagai aur dengan tebingJudgementHe had a good judgement. He told that he will try to put out the fire of a burning house.InsightGood insightPhysical ExaminationGeneral ExaminationHe was alert and conscious and was not in pain and respiratory distress. He is a thin gentlemana) Vital signTemperature: 37oCPulse:89 bpm, good rhythm, normal volumeBlood pressure: 116/78 mmHgb) Hand The capillary refill time was less than 2 seconds. His hands were pink and dry on both sides, warm temperature. No clubbing, peripheral cyanosis, no koilonychias, no nicotine stain on index and middle finger, no scar, and no deformity. No tenderness, weakness, swelling or rashes on the hands. There were tattoo found on his right forearm. No venipuncture mark on his forearm.c) Head and neckThere was no yellowish discolouration of the sclera and no conjuctival pallor. His tongue was pink and moist. The oral hygiene was good.No thyroid enlargement, palpable lymph node and jugular venous pressure was not raised.d) LegThere was no pedal edema.

Respiratory examination Chest moved with respiration. No surgical scars, dilated veins and chest deformity. Trachea was not deviated. Apex beat was at 5th intercostal spaces mid-clavicular line. Upper chest moved symmetrically. The lower chest expansion was normal. It was resonance on both sides of the chest in percussion. Equal air entry on both lungs. No adventitious sounds.

Cardiovascular examinationNo visible pulsation, surgical scars and chest deformity. Apex beat is at 5th intercostal space, mid-clavicular line. No parasternal heaves and pulmonary heaves. First and second heart sounds were heard at the mitral area with normal intensity. No added sounds. No murmur heard. No basal crepitation was heard.Abdominal examinationThere was no surgical scar. Abdomen was not distended and move with respiration. No dilated veins and striae.No tenderness and guarding. No mass was felt. Liver was not enlarged. No enlargement of spleen. Kidney was not ballotable. Abdomen was resonance. No dullness suggesting ascites. Bowel sounds were heard. No renal bruit.Formulation for diagnosis and differential diagnosisBased on the history and examination, the diagnosis for Mr T is major depressive disorder. The differential diagnoses were Bipolar disorder type 1 and borderline personality disorder. The evidences that support the diagnosis which is major depressive disorder were he had difficulty to fall asleep and had an early awakening. He slept 2-3 hours a day since he had problems with his girlfriend. He claimed that he felt fresh when he woke up early in the morning. He also told that he had low mood since few days prior to admission due to the problem with his girlfriend. He also had loss of appetite since he had quarrelled with his girlfriend. He had lost 4kg of his weight since he had a problem with his girlfriend. Furthermore, he also claimed that he had lost of concentration because he kept thinking about his girlfriend. His loss of concentration made him involved in an accident. Moreover, he also had cut himself at the left forearm due to stress with his girlfriend. So, Mr T had 5 symptoms of the DSM-IV criteria for major depressive disorder.For the differential diagnoses, bipolar disorder was also one of the diagnosis because he felt fresh when he woke up in the morning even though he had only 2 hours of sleep. During my observation, he seems he had inflated self-esteem because he told that his girlfriends brother was not brave enough to have a fight with him even though his girlfriends brother carried a weapon such as knife or parang and himself just wanted to fight with a bare hand. When they met, he claimed that his girlfriends brother just talked to him nicely. However, he did not have pressured speech, flight of ideas, increase in goal-directed activity. So, the DSM-IV criteria for bipolar disorder was not met.Last but not least, the differential diagnosis was borderline personality disorder. He claimed that he was scared that he will not be loved again after his father had passed away. So, he scared that he will be abandoned. Furthermore, he also had recurrent self-harm which he cut his forearm. Furthermore, he also told that he easily became angry after his fathers death. However, he did not have the other symptoms of borderline personality disorder. Therefore, the DSM-IV criteria for borderline personality disorder was not fulfilled.

Management1) Investigationa) Blood investigation Complete blood count Fasting blood sugar Thyroid function testb) Urine for substance abuse2) Psycotherapya. Psychoeducationb. Cognitive behavioural therapyc. Family counselling3) Start selective serotonin reuptake inhibitor for depression4) Start on Seroquel for his hallucination and mood disorder5) Refer to social worker officer to improve his concentration