Identification DataName:Mr R

Age:43 years old

Sex:Male

Occupation:Unemployed

Marital Status:Single

Race:Chinese

Religion:Islam

Address:Ayer Tawar, Perak

Date of admission:2/8/2014

Registration Number:PK058145

Chief ComplaintMr R was brought in by the police due to aggressive behaviour for 1 day which he broke his adopted mothers door to take a camcorder and some money.History of Presenting IllnessApproximately 3 weeks ago, Mr R had burnt all the dirty children clothes at the side of the road at his house. He claimed that he burned all the children clothes because there was a priest/Sami that told him that he was being sihir a year ago. He claimed that he always lost when he want to go to his house in Kuala Lumpur which he bought and lived by himself. He was told by the priest that he must burned down all the children clothes to remove the sihir. Then, his adopted mother made a report in a police station and the police brought him to see a Psychiatrist in Psychiatric Clinic in Seri Manjung. The doctor gave him medication which he did not know the type of medication given. A few days later, he went to Kuala Lumpur to take zakat money from Majlis Agama Islam Selangor about RM400. He went there by bus and his adopted mother knew that he went to Kuala Lumpur to take the zakat money. He stayed in Kuala Lumpur for a few days and he slept in a few mosques because he claimed that he needs to sleep in a few mosques to remove the sihir. After that, he went backed to Ayer Tawar. At home, he broke his adopted mothers door to take a camcorder which he claimed that he bought it himself by using his money but his adopted mother told him that the camcorder need to be repaired. He also took some angpow money which belonged to his adopted mother. Later, his adopted mother called the police and he was brought into Hospital Bahagia Ulu Kinta.He claimed that he had 3rd person auditory hallucination everyday which he will experience when he was doing nothing. There were 3 male voices talking with each other and himself is a listener. The voices talked about what will happen to his enemies. He had delusion of grandiosity which he claimed that his father is King Abdullah and his mother is Queen Munirah of Saudi Arabia. He also claimed that his maternal grandfather is King George V and his uncle is King Edward. He also claimed that he had RM70 billion in his bank account and claimed his adopted mother tried to use his money. He also claimed that he is the President of Saudi Arab Corporation and Malaysia Strategist Movement Intelligence.He also denied any usage of drug or substance. He is a smoker. He smoked since 7 years ago about 1 pack per day. He did not take alcohol. He had no trouble of sleeping. He always sleeps 6 hours a day. He had no loss of appetite, loss of weight, suicidal thought, increase in pleasurable activity, and distractibility.Previous Psychiatric History Previously, he had been admitted into Hospital Bahagia Ulu Kinta for 4 times. The first admission was on 2005 because he became aggressive and he hitted his family members. He also claimed that he was a well-known person who married with a well-known person. He had been admitted into Hospital Bahagia Ulu Kinta for 5 times from 2005 to 2009. His last admission was in 2009 at forensic department. In 2007, he was arrested in a prison in Sungai Buloh for having a gun with 2 bullets inside Past Medical HistoryMr R denied medical illnessPast Surgical HistoryNo surgery had been done.Family HistoryHe claimed that his father is King Abdullah, 93 years old and his mother is Queen Munirah, 83 years old. He also claimed that he is the eldest out of 3 siblings. His younger brother is Prince Mutayib, 7 years old work as Defence Minister of Saudi Arabia. His youngest sibling is Princess Sara. But mother stated that his husband is 73 years old and she is 70 years old. According to his mother, his husband had schizophrenia and was under follow up in Hospital Manjung.Personal HistoryAccording to his mother, he was delivered through spontaneous vaginal delivery. He had normal developmental milestone. Academic RecordsMr R claimed that he started going to school in Military school in London when he was 6 years old. He did not take UPSR and PMR examination because he was studying in University King Abdul Aziz in Saudi Arabia. Mr R told that he took SPM and STPM. He passed his SPM and STPM examination.Work RecordHe claimed that he was the President of Saudi Arab Corporation and he was the Malaysia Strategist Movement Intelligence.Sexual ExperienceHe either masturbates or went to massage home once a month. Marital HistoryMr R claimed that he was married and had 4 children. His wife and children lived in Saudi Arabia currently. His wife and children lived in Saudi Arabia because it is safer to live there than in Malaysia.Pre-morbid PersonalityMr R claimed he did not remember his personality because his mind is emptyMental Status Examination1) General AppearanceMr R was in hospital attire, well kempt and in good hygiene. He also had tremors at his right hand. He had good eye contact and no odd mannerism. He fairly cooperative

2) SpeechHe had a loud voice. His speech was well articulated, irrelevant and coherent. No loosening of association and circumstantiliaties.

3) MoodEuthymic

4) AffectFlat and was appropriate to content

5) Thought contentPresence of delusion of grandiosity. No suicidal and homicidal thought

6) Perceptual disturbancesNo auditory hallucinations and illusions

7) Sensorium and CognitionAlert

8) OrientationHe was orientated to time, place and person

9) Attention and ConcentrationHe was able to tell months is reverse order

10) Memorya. Immediate: He able to recall 4 out of 5 objects after 5 minutesb. Recent: He was able to tell the winner of World Cup 2014c. Remote: He able to remember his birth date

11) Fund of knowledgeHe knew the prime minister of Malaysia

12) AbstractHe was unable to explain similarities between apple and orange. He claimed the similarities for both of the fruits are round.

13) JudgementHe had good judgement. He told that he will try to extinguish the fire if he saw a house was burning

14) InsightHe had partial insight. He knew he had mental illness. However, he told that he only took his medication when he felt that he needed it.

Physical Examination

General ExaminationHe was alert and conscious and was not in pain and respiratory distress. He is a thin gentlemana) Vital signTemperature: 37oCPulse:92 bpm, good rhythm, normal volumeBlood pressure: 124/84 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 palmar erythema, muscle wasting, Oslers node and Janeway lesion . 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 enlargement of lymph node, thyroid and jugular venous pressure was not raised.d) LegThere was no pedal edema.

Respiratory examination The 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 on percussion. No dullness suggesting ascites. Bowel sounds were heard. No renal bruit.Provisional Diagnosis

Relapse Schizophrenia

Differential Diagnosis

Bipolar disorder type 2

Formulation for diagnosis and differential diagnosis

As for Mr R, the symptoms clearly showed that he had schizophrenia. The facts that support the diagnosis were he had disorganized behaviour which he burned down all the children clothes which he claimed that he was being sihir. He also broke his mothers bedroom door to take his camcorder and took his mothers angpow money. Furthermore, he had delusion of grandiosity which he claimed that his father was King Abdullah and he had RM70 billion in his bank account. Moreover, he also experienced auditory hallucination which he heard 3 voices talking about what will happen to his enemies. So, he had the positive symptoms of schizophrenia. Furthermore, during mental status examination he cannot tell the similarity between apple and orange was fruit. Instead he answered, the similarity was round. Besides that, he had past history of schizophrenia which he had been admitted into Hospital Bahagia Ulu Kinta for 5 times.

Management

1) Investigations:a. Full blood countb. Electrocardiogramc. Renal profiled. Random blood sugar2) Get more history from his parents regarding compliance and stressor3) Psycho-education for his family4) Refer him to social welfare worker for him to get a job5) Plan for home-care.6) Start on antipsychotic such as Risperidone 1mg BD8