Identification DataName:Mrs S

Age:42 years old

Sex:Female

Education:Master in Computer Science

Occupation:Tuition teacher

Marital Status:Separated

Race:Indian

Religion:Hindu

Address:Setiawan, Perak

Date of admission:7/3/2014

Registration Number:PK063533

Chief complaintMrs S was brought by police under court order because she harmed her son and tried to commit suicide on 24 June 2013.History of Presenting IllnessIt was started on November 2012 when she became depressed due to financial problem. She was a tuition teacher and she lost a lot of her students. She claimed the students did not want to come to her tuition because she had made a change in the timetable of the tuition class and she became strict to her students. She worked hard and always stayed up late until night to finish the books and exercise that she made herself for her students. She only slept 1 hour every night and she worked every day. Due to lack of sleep, she will have low energy when she woke up. However, she still continued to work hard every day. She also claimed that she had lost of concentration. She had no loss of appetite. She also felt worthless because she thought that she was a failure because she cannot retain most of her students. At that time, she did not have any suicidal ideation. After 1 month, she started to hear voices. It was once in a while. There were a few people and the voices always supporting her to teach her students. So, she was becoming more enthusiastic to teach her students. She also claimed that the voices told her about the future. For instance, the voices told her which students will not come to her tuition class. She also experienced thought insertion which she claimed that she can read someone thought that was passing by when she was eating in a restaurant. However, she denied delusion, thought broadcasting, distractibility, increases in goal directed activity and inflated self-esteem.Her condition became worsened in April 2013. The voices that she heard appeared from morning until night. There were a few people and the voices kept scolding her and tormenting her. She did not seek for treatment because she claimed that she was gifted because she can know the future and can read someone minds. On 23rd of June, the voices command her to kill herself and her son by driving her car into the ocean in Lumut. There were 2 voices. One voices told her to kill herself and her son while the other voice told her to stop kill herself and her son because the ocean is a holy place and it was not good to have a dead bodies there. So, the voices stop her from killing herself and her son. Furthermore, she claimed that she felt that she had many enemies. The enemies were the parents of her students and the other tuition teachers. She claimed that the parents wanted to harm her because she had scolded their children badly. She also claimed that the other teachers were jealous of her because she had a lot of students. So, she felt that she was being harmed. Besides that, she also felt that somebody had used charm on her and that was the reason she can hear voices.The next day which was 24th of June 2013, she heard the voices told to kill her son and commit suicide. She heard voices of three people which command her to kill her son. So, she hit her sons right side of the head by using a hammer 9 times. Her son sustained serious injury. Then, the voices told her to kill herself by cutting at her left wrist and left anterior neck. Then, the voices also told her to call the police. She claimed she did not plan any homicidal or suicidal attempt. She just followed the voices that she heard. Then, the police came and brought her son to Hospital Setiawan for treatment and her son was sent to Hospital Manjung for MRI and was admitted for about 1 and a half month. She was being detained for 6 days. After she was released for 1 week, she was brought into a court. After that, she was sent to Tanjung Rambutan for 1 month for observation. Then, she was being jailed into Penjara Tapah for 8 months and lastly, she was sent back to Hospital Bahagia Ulu Kinta.Past Psychiatric HistoryIn 1994, she claimed that she had depression due to personal problem. She refused to tell about the personal problem. At that time, she was in a university taking 4 year course. She stopped after 1 year and seeks for treatment. She complied to the treatment and she was completely treated. After she had been treated, she continued her studies. She was not admitted into any hospital.In 2005, she also claimed that she became depressed because his son was diagnosed with autism. She felt guilty, blame herself and questioning herself whether she had done anything wrong. However, she did not seek for treatment and her depression resolve by itself.Past Medical HistoryNo past medical historyPast Surgical HistoryNo surgery had been doneFamily History

80 years old Diabetic Stroke Chronic schizophrenia

46 years old Nurse Married Stayed in Kuala Lumpur

41 years old Technician Married Stayed in Ipoh

Mrs S is the second out of 3 siblings. Her father is alive while her mother had passed away due to stroke at the age of 66 years old. Her mother also had schizophrenia which even the treatment cannot control her symptoms. Her father is 80 years old and he had diabetes and she claimed that her uncle also had schizophrenia. Her siblings are alive and healthy. Her elder sister is married and live in Kuala Lumpur and works as a nurse in Hospital Damansara Damai. Her younger brother is married and stayed in Ipoh with her father. She claimed that all her siblings including her support their own family.Personal HistoryShe was born term and through spontaneous vaginal delivery. She claimed her developmental milestones were normal. For her academic records, she started school since she was 6 years old. She got all As for her UPSR, 8As in her SRP and scored 6 As with 3 credit for her SPM. As for her STPM, pass her examination and she passed her degree in UM. She managed to get full certification for her Master in Computer Science. She claimed she did not playing truant during her school days. She was an active girl who involved in socities such as Indian Socities, prefect and she was an active in doing sports such as netball and hocket. She represented her school in netball and hockey. She claimed that she had many friends in primary and secondary school and denied any problems with her friends. However, when pursuing her degree, she did not have many friends because all of her friends in primary and secondary schools were pursuing in other courses. She also claimed that she had no friends because she paid a lot of concentration on her son. She did not have time to socialise with her friends and make new friendsWork RecordShe started to work as a lecturer in private college in Ipoh. Later, he went to UTP because UTP offered a better salary. When she was working in UTP in 2005, her son was diagnosed with autism at the age of 9 years old. She became depressed. She felt worthless, blame herself, cannot eat and cannot sleep. She did not see doctor and later her depression resolve by itself. Then, she decided to become a tuition teacher because her timetable will be more flexible and she can focus more on her son. She earned RM2000 to RM3000 per month as a tuition teacher.Marital HistoryShe was married when she was 28 years old. She had been separated from her husband 14 years ago. She claimed that she was physically abuse by her husband. She ran away from her husband in 2000. Sexual HistoryShe reaches her puberty at the age of 11 years old. She had normal menstruation. The menstruation period lasted 7 days and her menstruation is a cycle of 28 days. She did not experience menorrhagia and amenorrhea. She did not expose to any sexual activities.Alcohol and Drug UseShe denied taking alcohol and substance such as amphetamine, heroin and cocaine.Pre-morbid personalityShe claimed that she is an independent person. She did not share her problems with other people. She likes to solve her problem by herself. She is also an active person who enjoys teaching. When she was angry, she will shout and raise her voices.Mental Status Examination1) General AppearanceShe was wearing her own clothes, well hygiene and had good posture. She had good eye contact, no odd mannerism.2) SpeechShe was speaking in English. Her voice was soft, well-articulated, relevant, coherent and talking rationally. No loosening of association, flight of ideas.3) MoodEuthymic.4) AffectBroad and appropriate to content5) Thought contentShe did not have delusion, suicidal and homicidal thought6) Perceptual DisturbancesShe did not have hallucination7) Sensorium and Cognitiona. Consciousness : She was alertb. Orientation : She was orientated to time, place and person.c. Attention and Concentration : She can do serial subtraction of 7 from 100. d. Memoryi. Immediate- She can recall 5 out of 5 objects after 5 minutesii. Recent memory- She was able to remember the day she was admitted.iii. Remote memory- She able to remember her birth datee. Fund of knowledge : She knew who was our prime minister which she answered Datuk Seri Najib Tun Razak.f. Abstract : She able to tell the similarity between apple and orange. She told the similarity was both are fruits.8) JudgementShe had a good judgement. She told that she will call a fire-fighter if a house was on fire9) InsightShe had a good insight. She knew the disease that she had and she comply to her medicationPhysical ExaminationGeneral ExaminationShe was alert and conscious and was not in pain and respiratory distress. She is a medium-built lady.a) Vital signTemperature: 37oCPulse: 70 bpm, good rhythm, normal volumeBlood pressure: 109/66 mmHgb) HandThere were 2 well-heal scars from the cut that she done on the left wrist measuring 5cm long. The capillary refill time was less than 2 seconds. Her hands were pink and dry on both sides, warm temperature, no palmar erythema, clubbing, peripheral cyanosis, no koilonychias, no nicotine stain on index and middle finger, no muscle wasting and no deformity. There were also no splinter hemorrhage, Oslers nodules and Janeways lesion. No tenderness, weakness, swelling or rashes on the hands. No tattoo found on her handc) 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.There was also 2 well heal scars on the left anterior neck of the patient. No enlargement of lymph node 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. There was no reduced air entry on the both lung. 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.Provisional DiagnosisMajor depressive disorder with psychosisDifferential Diagnosis1) Schizophrenia with secondary depression2) Schizoaffective Reason for Diagnosis and Differential DiagnosisThe likely diagnosis for Mrs S is major depressive disorder with psychosis. The timeline of her symptoms showed that she had depression first and followed by psychotic symptom. Initially in 2012, she had depression due to financial problem. She had the following symptoms which are present in DSM-IV criteria for major depressive disorder :1) Depressed mood2) Feeling of worthlessness because she cannot retain her students3) Diminished concentration4) Feeling fatigue5) Difficulty to fall asleepAfter a few months, she developed psychotic symptoms such as auditory hallucinations. She also had thought insertion which she claimed that she can hear the thought of people who were passing by at the restaurant. She also had persecutory delusion. For example, she felt that her students parents want to harm her because she scolded their children. She also felt that she was being charmed. Due to being charmed, she can hear the voices and know the future. Schizophrenia with secondary depression is one of the differential diagnosis for this patient because her auditory hallucination was not congruent with her depressive mood. The voices that usually present in depressive patient always told that the patient is useless and not worth to live. However, in this patient, the voices was not congruent to the mood. Furthermore, she had strong family history of schizophrenia and she had symptoms of schizophrenia which were auditory hallucinations, thought insertion and persecutory delusion. Therefore, she might have schizophrenia with secondary depression.The last differential diagnosis was schizoaffective. She had psychotic symptoms which suggested schizophrenia and also mood symptoms at the same time. However, she did not have 2 weeks period of schizophrenia in the absence of mood symptoms. She always felt depressed due to financial problem and the first symptom that she had was depression.Management1) Investigationa. Full blood countb. Electrocardiogramc. Renal profiled. UFEMEe. RBSf. Chest X-ray2) Get more detailed history from relatives or father.3) Treatmenta. Biological : Anti-depressants, antipsychotic such as risperidoneb. Psychological : Psychoeducation, cognitive behavioral therapy, supportive therapy

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