LiaisonCase Presentation

By:Farah Adibah Kasmin

Undergraduate

UiTM

Demographic Details

• Patient’s name: J

• R/N: 922753

• Age: 33 years old

• Sex: Female

• Race: Malay

• Status: Married

• Occupation: Housewife

• Ward/Hospital: 4A, Selayang Hospital

• DOA: 25/2/2013

• DOC: 27/2/2013

• Informant: Patient

• Language spoken: Malay

Chief Complaint

• Madam J, a 33 years old Malay married lady, Para 1 and a housewife came to Selayang Hospital for her 2nd hospitalization to Surgical Ward since 12 days ago (25th February 13) for further management of her lower abdominal wound and was referred to psychiatry after had persistent low mood for 1 month duration.

HOPI• On 8th November 12, this patient underwent Elective LSCS for PP Type II at Hospital

Kajang. 4 hours post operatively, she developed severe PPH and underwent several emergency laparatomies to secure the bleeding.

• She had prolonged ICU stays and multiple hospital transfer from Hospital Kajang to UKM Medical Centre, GHKL and Selayang Hospital. So, she actually never went home.

• Only regained her consciousness after transfer into Surgical Ward at GHKL that was on 8th February 13 (~1/12)

• Since then, she started:

• Felt sad almost everyday and cried all the time as she thinks that the her illness is unresolving

• Felt hopeless and worthless as due to her current condition now she becomes dependent to her husband and mother in-law. She thinks that she has burden them.

• Also felt excessive guilty because unable to take care and attend her baby as other mother

• Had history of intermittent passive death wishes. However, there was no suicide thought.

• Lost interest to read novel as that was her hobby before.

• She was hardly fall sleep, and sometimes woken up at night especially when the staff nurse came and took the vital signs and can’t sleep after that

• She also refused to talk to any staff in the ward

• Became irritable when the staff nurse did not allow her family members to visit her. So, she scold the staff nurse.

• Along the course of illness, become thinner

• No fatigue or loss or energy and her appetite were normal

• Otherwise, denies any hallucination or grandiose delusion, increase of energy level and directed goal-activities.

From GHKL, she persistently had the low mood until her 1st

hospitalization to Selayang Hospital on 15th Feb 13.

She was not sure if there is any medication has started for her.

After 6 days she was allowed for a home leave as she missed her family so much.

Upon this 2nd hospitalization, she claimed that she became less sad and was very happy after seen and able to hold her baby at home.

Protective factors:

1. A daughter

2. Supportive husband and mother in law

Past Medical History

Critical illness of myopathy. Currently on physiotherapy and ambulating with wheel chair.

Past Obstetric History

• Antenatal: GDM on diet control and Placenta praevia Type II

• Perinatal: Delivered a baby girl, full term weight 3.0 Kg via ELLSCS

• Postnatal: 4 hour post ELLSCS had post partum haemorrhage, need to undergo several emergency laparotomy.

• Never breast feed the baby. Use formula milk

• Currently, the baby is 4/12 and doing well

Past Surgical History

• Appendicectomy at Muar Hospital when she was 12 years old

• Due to PPH, underwent 8 laparotomies.

- 6 at Kajang Hopital

- 2 at UKM Medical Centre

• After that, transferred to Selayang Hospital for poor healing of midline wound with colocutaneous & rectovaginal fistula.

1/10/12Admitted to

Kajang Hospital for PP Type II @ 33weeks

8/11/124hrs post ELLSCS,

developed PPH. Patient collapsed, intubated,

transfused to ICU

9/11/12 -1st laparatomy with bilateral internal iliac

artery ligation-2nd laparotomy with

subtotal hysterectomy

12/11/12-3rd laparotomy with

splenectomy-4th laparotomy due to

bleeding, packing done

14/11/12-5th

laparotomy for removal of abd pack

15/11/12-6th laparatomy, another

abd packing done-Tranfered to UKMMC

Hepatobiliary Team

17/11/12-7th laparotomy

For abd pack removal

26/11/12-Tracheostomy

was done

13/12/12-Transferred to GHKL

under colorectal department

8/2/13-Transfer to HKL Surgical Ward

15/2/13-Transfer to Selayang Hospital

for colocutaneous & rectovaginal fistula

25/2/13-Readmitted again

to SelayangHsopital for

wound dressing

7/12/13-8th laparotomy for

infected wound and burst abd.

52 days ICU stay

Drug History• Taking Sea Cucumber Jelly BD

Allergy History• No allergy toward food and medication

Family History

70 58

Madam J

Gout, HPTDM, HPT, CKD

Personal HistoryShe was born normally, no complication.

Studied at SK Laki-Laki Johor and SMK Ledang with average performance

Took distance course in baking for 2 weeks only due to financial problem

Became a factory worker for 3 years and a sales girl at ‘kedai kasut’ for 7 years

Married at the age of 31 with a taxi driver. Average monthly income RM 1200

Non-smoker, non-alcoholic, non-abuser of drugs

No history of police charges

Live in a flat at Level 7 in Sg Long Kajang with good basic amenities

Pre morbid personality: She was a happy go lucky, talkactive, very friendly, concentrate in doing her works and love to cook for her husband

Mental Status Examination

APPEARANCE

Wearing green hospital dress. Lying flat supported with one pillow.

She looked well groomed, smiling when being approached and was cooperative. There were no abnormal movements and the eye contact was good. The rapport was good.

SPEECH

Speak in ‘Bahasa’ with normal rate and average volume

Coherence, relevant well articulated and no pressure in speech

MOOD AND AFFECT

Her mood was euthymic, and his affect was appropriate.

PERCEPTUAL DISTURBANCE

She did not have any perceptual disturbances such as hallucinations or illusions.

THOUGHT CONTENT

Her thought process was normal with no loosening of associations and no flight of ideas.

Currently, she did not have any suicidal and homicidal thoughts. There was no delusion, obsessional thought, preoccupations, flashback, recurrent dreams or nightmares.

COGNITION

Orientation

Orientated to time, place and person

Memory

a) immediate memory – he was able to immediately recall 3 objects which were cawan, meja, kerusi

b) short term memory- able to recall the previous 3 items after 5 min

c) long term- remembered her birthday date which is on 5th September 1979

Attention & concentration

Was able to do serial 7

Intelligence

She knows the Malaysian’s independance day and the current prime minister of Malaysia

Abstraction

She was able to give the meaning of ‘sikit-sikit, lama-lama jadi bukit’. She knows the similarity

between apples and orange which is fruit.

Insight and Judgement

Good judgement when ask if her house is on fire she will call firemen

Her insight was good as he was aware that his experiences/problem was abnormal.

PHYSICAL EXAMINATION

General Examination• Patient was lying supine comfortably and not in pain or any acute distress and• She is cachexic and clinically looks pink• No jaundice or cyanosis• Both of her hands are warm and moist

Vital signs

Temperature: 37.0 oCBlood pressure: 120/75Pulse rate: 92 bpm regular rhythm normal volumeRespiratory rate: 16 bpm

Systemic Examinationa) Abdominal Examination

Inpsection: The abdomen if flat, moves with respiration. There is a midline laparotomy scar measured about 8cm which is well-healing with no discharge. There is also a dressing. It is clean with no blood soaked.

Palpation: Soft and no tender. No organomegalyAuscultation: Bowel sound present

b) Neurological Examination

Inspection: Foot drop of both foot. Muscle wasting of both limbs. No abnormal movement or any neurocutaneous sign noted

Tone: Hypotonia of both feet

Power: 2/5 for dorsiflex of both feet

Reflex: Hyporeflex for ankle reflex

Sensation: Equal for pin prick, light touch and proprioception

Cerebellar sign (Heel and shin test) : Intact

Summary

Madam J, a 33 years old Malay married lady, Para 1 and a housewife came to Selayang Hospital for her 2nd hospitalization to Surgical Ward since 12 days ago (25th February 13) for further management of her lower abdominal wound and was referred to psychiatry after had persistent low mood for 1 month duration.

She had a sad feeling almost everyday, hopeless and worthless with excessive guilty, anhedonia, irritability and history of intermittent passive death wishes, impaired social function and all these full filled the DSM-IV criteria for Major Depressive Episode (MDE)

Otherwise, denies any hallucination or grandiose delusion, increase of energy level and directed goal-activities.On examination, all MSE component are normal.

Provisional DiagnosisMDD secondary to Medical Condition

Points to support

• Feeling sad almost everyday• Feeling of hopeless and worthless with excessive guilty• Anhedonia• Irritability • History of intermittent passive death wishes• Impaired social function

1/12

Differential Diagnosis

• Post partum blues

Points to support:Full filled the DSM-IV criteria for MDE

Points to against:Does not full fill the DSM-IV criteria for Postpartum Onset Specifier

It should be within 4 weeks after delivery but for this patient the onset of symptoms developed 3/12 after delivery

Final Diagnosis

• Axis I: Major Depressive Disorder

• Axis II: -

• Axis III: 1. Critical Illness of Myopathy,

2. Colocutaneous and rectovaginal fistula

• Axis IV: 1. Predisposing:-2. Perpetuating: Prolonged hospital hospitalization3. Precipitating: -

• Axis V: 90-81

Managementa) Psychiatry Plan:Tab Sertraline 100mgRefer counsellor for motivational counsellingLink to Selayang Hospital Islamic Centre to guide in performing daily prayersAdvise husband to enhance her motivationOn 5/3 – discharge from psyTCA as outpatient clinic 6/52b) Ortho Plan:Start on Tab Methylcobalt 500mg BDContinue physiotherapy and thermoplastic splintAdvise for self-exerciseTCA as outpatient clinic 2/12c)Surgical Plan:To complete Antibiotic for 2/52