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FARAH HUSNA MOHD FADZIL


040100848
Post-Test Psychiatry
11 Jun 2009

MENTAL STATUS EXAMINATION

I. PSYCHIATRY HISTORY

A. IDENTIFICATION

Name : Mr Z
Age : 46 years old
Sex : Male
Marital Status : Married with 3 children
Religion : Islam
Education level : Master Degree in Mechanical Engineering
Address : Kangar, Perlis
Occupation : Lecturer in local universities
Source of referral : 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
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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 I: Bipolar type 1, most recent manic episode


Axis II : Impulsive personality
Axis III : Hipertension, Diabetis Mellitus
Axis IV : Non
Axis V: GAF Scale 81-90 ( Absent or Minimal symptom )
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V. DIFFERENTIAL DIAGNOSIS
 Bipolar type 2 Disorder
 Schizoaffective Disorder

VII. PROGNOSIS
Good Poor
Family history Grandmother having
psychotic symptom
but never seek
medication.
Compliance Comply
Onset Early adulthood
Support Family supportive
Educational level High
Economic status Good
Marital status Good
Symptom Manic & depressive
Gender Male
Function Mildly altered
Duration 22years

Overall prognosis : good


VIII. TREATMENT PLAN

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

• 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)