Mental Status Examination

1 FARAH HUSNA MOHD FADZIL 040100848 Post-Test Psychiatry 11 Jun 2009 MENTAL STATUS EXAMINATION I. PSYCHIATRY HISTORY A. IDENTIFICATION Name Age Sex Marital Status Religion Education level Address Occupation Source of referral

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Mr Z 46 years old Male Married with 3 children Islam Master Degree in Mechanical Engineering Kangar, Perlis Lecturer in local universities Patient

B. CHIEF COMPLAINT Patient came to the psychiatric clinic on follow up and to continue medication he received since 2002

C. HISTORY OF PRESENTING ILLNESS Previously, Mr.Z was apparently fine until the first symptoms appeared in year 1987 when he was working at Kolej Pengurusan Penerbangan. They were manifested as several weeks of dramatic mood changes, feeling high of excitement, overactivity, suffered from lack of sleep, being restless and having an unacceptable behaviour . These were followed by few days of depression during which he slept a lot, felt lost of energy and not interested in anything. The symptoms of elation and depressive alternately appeared and within few months, patient was back to his usual self again before having the next attack few years later. During his energetic periods,Mr. Z was optimistic,self-confident and had lots of ambitious plans. He claims to have a good handwriting

2 that he was awarded the best handwriting. He wants to be the richest man by producing a new helicopter which is designed by him. Subsequently he realized that a big project such that couldn’t be done individually. As a result he stops the project eventhough he had designed the model of helicopter. Patient also claimed he wanted to propose singer/actress, Erra Fazira for marriage. At this state, patient also said that he behaves impulsively and his sexual desire increased impulsively. He also claimed spending large sums of money on unnecessary things such as treat his friends at any expensive restaurant for no reason.Patient also claimed giving RM2 to every person/strangers he met. During his depressed periods, he often stays in bed all day due to fatigue circumstance,no interest in any activities,feeling down and depressed.He also had a thought of suicide but never had any attempt of suicidal. Although patient denied any spiritual involvement regarding his condition, Mr. Z’s parents and uncle who noticed his ‘changes’referred him to ‘Bomoh’ as they believe that patient was being possessed by some spirit. Patient claimed that he was treated ridiculously by the ‘Bomoh’. Mr. Z denied any spiritual help regarding his condition. His parents and uncle who noticed his ‘changes’, bring him to get help from ‘Bomoh’ as they believe that Mr. Z being possessed by some spirit. Patient then claimed that he was treated ridiculously by the ‘Bomoh’. He also believes that his uncle had a bad intention towards him from the time when his uncle said he was crazy.Patient was then brought to Hospital Lam Wah Ee, Penang by his parents and he was hospitalized there. Subsequently, patient was frequently admitted in different hospital due to same episode.In 1991, patient was hospitalized due to his manic state and then he was put on medication. In September 2002, patient was studying in France and he ran out of medicine. As a result, the same episode occurred in the same year that patient had to be hospitalized in a Psychiatric Hospital in France.Patient was sent back home in same year and continued his medication at Hospital Tunku Fauziah,Perlis until today. D. PAST MEDICAL & PSYCHIATRIC HISTORY Patient had hypertension and diabetis mellitus. He had been follow up till now at outpatient department of HTF. E. FAMILY HISTORY Grandmother had psychotic symptom after giving birth but never seek medication

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F.PERSONAL HISTORY CHILDHOOD HISTORY Patient had normal development during childhood and teenage years. He continued doing master and allegedly dropped out due to mental illness SCHOOL HISTORY He identify himself as an active student where he always involved in lots of school activities. RELIGIOUS BACKGROUND He came from a religious family background. MARITAL HISTORY Married with 3 children : i)13 years old daughter, ii)11 years old son iii)6 years old daughter Patient claimed his wife and children understands his problem and there is no other significant problems in his marriage. OCCUPATIONAL HISTORY Claimed not having problem with his occupation, he feels comfortable at his working place as all his colleges understands him. DRUGS, ALCOHOL & TOBACCO HISTORY Nil MENTAL STATUS A. APPEARANCE & BEHAVIOR a. Patient appears well dressed,excited,and talkative. B. GENERAL DESCRIPTION He is well dressed with casual clothing C. SPEECH He speaks Malay rapidly, jumping from one idea to another ( flight of ideas), spontaneously answering D. MOOD & AFFECT Euphoric and easily distracted. E. THOUGHT Logical and goal oriented

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F. THOUGHT CONTENT Patient has grandiosity delusion.He wants to be the richest man and produce a helicopter.He claims to have a good handwriting that he was awarded the best handwriting.Patient also wants to propose singer/actress, Erra Fazira for marriage. Patient claimed his uncle had a bad intention towards him and being told that he was crazy. Patient does not have any phobia. G. PERCEPTION No hallucination or illusion H. ALERTNESS Alert I. ORIENTATION Oriented to time,place and person J. CONCENTRATION Good. Able to count backwards by 7 starting from 100 K. MEMORY No impairment in immediate, recent and remote memory. L. FUND OF KNOWLEDGE Very Good M. ABSTRACT REASONING Understand Malay Proverbs N. INSIGHT True Emotional Insight.Patient knows of his disease and it’s significant.Heis willing to be treated. O. JUDGEMENT Good Social & Personal Judgement IV.PROVISIONAL DIAGNOSIS Axis Axis Axis Axis Axis

I: II : III : IV : V:

Bipolar type 1, most recent manic episode Impulsive personality Hipertension, Diabetis Mellitus Non GAF Scale 81-90 ( Absent or Minimal symptom )

5 V. DIFFERENTIAL DIAGNOSIS  Bipolar type 2 Disorder  Schizoaffective Disorder VII. PROGNOSIS Good Family history

Compliance Onset Support Educational level Economic status Marital status Symptom Gender Function Duration

Poor Grandmother having psychotic symptom but never seek medication.

Comply Early adulthood Family supportive High Good Good Manic & depressive Male Mildly altered 22years

Overall prognosis : good VIII. TREATMENT PLAN 

Non pharmacological : i) basic counseling ii) psyco-education

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Pharmacological : i) Valproate 200mg/day ii) Lithium 300mg/day Here, I got 2 choices of drugs.First, I would like to start with Valproate with the minimal dose.I will then monitor his condition and if the symptom persist, I’ll increase the dose till the symptom disappear. If maximum dose is not effective to him, I’ll change Valproate to Lithium with minimum dose as the early prescription and will increase it gradually until the symptom dissappear.( I won’t combine it with anti-psychotic as this patient is diabetic)