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
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