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Identification Data

Name

: Mr R

Age

: 43 years old

Sex

: Male

Occupation

: Unemployed

Marital Status

: Single

Race

: Chinese

Religion

: Islam

Address

: Ayer Tawar, Perak

Date of admission

: 2/8/2014

Registration Number

: PK058145

Chief Complaint
Mr R was brought in by the police due to aggressive behaviour for 1 day which he broke his
adopted mothers door to take a camcorder and some money.
History of Presenting Illness
Approximately 3 weeks ago, Mr R had burnt all the dirty children clothes at the side
of the road at his house. He claimed that he burned all the children clothes because there was
a priest/Sami that told him that he was being sihir a year ago. He claimed that he always lost
when he want to go to his house in Kuala Lumpur which he bought and lived by himself. He
was told by the priest that he must burned down all the children clothes to remove the sihir.
Then, his adopted mother made a report in a police station and the police brought him to see a
Psychiatrist in Psychiatric Clinic in Seri Manjung. The doctor gave him medication which he
did not know the type of medication given.
A few days later, he went to Kuala Lumpur to take zakat money from Majlis Agama
Islam Selangor about RM400. He went there by bus and his adopted mother knew that he
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went to Kuala Lumpur to take the zakat money. He stayed in Kuala Lumpur for a few days
and he slept in a few mosques because he claimed that he needs to sleep in a few mosques to
remove the sihir. After that, he went backed to Ayer Tawar. At home, he broke his adopted
mothers door to take a camcorder which he claimed that he bought it himself by using his
money but his adopted mother told him that the camcorder need to be repaired. He also took
some angpow money which belonged to his adopted mother. Later, his adopted mother called
the police and he was brought into Hospital Bahagia Ulu Kinta.
He claimed that he had 3rd person auditory hallucination everyday which he will
experience when he was doing nothing. There were 3 male voices talking with each other and
himself is a listener. The voices talked about what will happen to his enemies. He had
delusion of grandiosity which he claimed that his father is King Abdullah and his mother is
Queen Munirah of Saudi Arabia. He also claimed that his maternal grandfather is King
George V and his uncle is King Edward. He also claimed that he had RM70 billion in his
bank account and claimed his adopted mother tried to use his money. He also claimed that he
is the President of Saudi Arab Corporation and Malaysia Strategist Movement Intelligence.
He also denied any usage of drug or substance. He is a smoker. He smoked since 7
years ago about 1 pack per day. He did not take alcohol. He had no trouble of sleeping. He
always sleeps 6 hours a day. He had no loss of appetite, loss of weight, suicidal thought,
increase in pleasurable activity, and distractibility.
Previous Psychiatric History
Previously, he had been admitted into Hospital Bahagia Ulu Kinta for 4 times. The
first admission was on 2005 because he became aggressive and he hitted his family members.
He also claimed that he was a well-known person who married with a well-known person. He
had been admitted into Hospital Bahagia Ulu Kinta for 5 times from 2005 to 2009. His last
admission was in 2009 at forensic department. In 2007, he was arrested in a prison in Sungai
Buloh for having a gun with 2 bullets inside
Past Medical History
Mr R denied medical illness
Past Surgical History
No surgery had been done.
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Family History
He claimed that his father is King Abdullah, 93 years old and his mother is Queen
Munirah, 83 years old. He also claimed that he is the eldest out of 3 siblings. His younger
brother is Prince Mutayib, 7 years old work as Defence Minister of Saudi Arabia. His
youngest sibling is Princess Sara. But mother stated that his husband is 73 years old and she
is 70 years old. According to his mother, his husband had schizophrenia and was under follow
up in Hospital Manjung.
Personal History
According to his mother, he was delivered through spontaneous vaginal delivery. He had
normal developmental milestone.
Academic Records
Mr R claimed that he started going to school in Military school in London when he
was 6 years old. He did not take UPSR and PMR examination because he was studying in
University King Abdul Aziz in Saudi Arabia. Mr R told that he took SPM and STPM. He
passed his SPM and STPM examination.
Work Record
He claimed that he was the President of Saudi Arab Corporation and he was the
Malaysia Strategist Movement Intelligence.
Sexual Experience
He either masturbates or went to massage home once a month.
Marital History
Mr R claimed that he was married and had 4 children. His wife and children lived in
Saudi Arabia currently. His wife and children lived in Saudi Arabia because it is safer to live
there than in Malaysia.
Pre-morbid Personality
Mr R claimed he did not remember his personality because his mind is empty
Mental Status Examination
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1) General Appearance
Mr R was in hospital attire, well kempt and in good hygiene. He also had tremors at
his right hand. He had good eye contact and no odd mannerism. He fairly cooperative
2) Speech
He had a loud voice. His speech was well articulated, irrelevant and coherent. No
loosening of association and circumstantiliaties.
3) Mood
Euthymic
4) Affect
Flat and was appropriate to content
5) Thought content
Presence of delusion of grandiosity. No suicidal and homicidal thought
6) Perceptual disturbances
No auditory hallucinations and illusions
7) Sensorium and Cognition
Alert
8) Orientation
He was orientated to time, place and person
9) Attention and Concentration
He was able to tell months is reverse order
10) Memory
a. Immediate: He able to recall 4 out of 5 objects after 5 minutes
b. Recent: He was able to tell the winner of World Cup 2014
c. Remote: He able to remember his birth date
11) Fund of knowledge
He knew the prime minister of Malaysia
12) Abstract
He was unable to explain similarities between apple and orange. He claimed the
similarities for both of the fruits are round.
13) Judgement
He had good judgement. He told that he will try to extinguish the fire if he saw a
house was burning
14) Insight

He had partial insight. He knew he had mental illness. However, he told that he only
took his medication when he felt that he needed it.
Physical Examination
General Examination
He was alert and conscious and was not in pain and respiratory distress. He is a
thin gentleman
a) Vital sign
Temperature: 37oC
Pulse:92 bpm, good rhythm, normal volume
Blood pressure: 124/84 mmHg
b) Hand
The capillary refill time was less than 2 seconds. His hands were pink and dry
on both sides, warm temperature. No clubbing , peripheral cyanosis, no koilonychias,
no nicotine stain on index and middle finger, no scar, and no deformity. No palmar
erythema, muscle wasting, Oslers node and Janeway lesion . No venipuncture mark
on his forearm.
c) Head and neck
There was no yellowish discolouration of the sclera and no conjuctival pallor.
His tongue was pink and moist. The oral hygiene was good.
No enlargement of lymph node, thyroid and jugular venous pressure was not
raised.
d) Leg
There 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 5 th intercostal spaces midclavicular line. Upper chest moved symmetrically. The lower chest expansion was
normal. It was resonance on both sides of the chest in percussion. Equal air entry on
both lungs. No adventitious sounds.
Cardiovascular examination
No visible pulsation, surgical scars and chest deformity. Apex beat is at 5 th
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 examination

There 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 on
percussion. No dullness suggesting ascites. Bowel sounds were heard. No renal bruit.
Provisional Diagnosis
Relapse Schizophrenia
Differential Diagnosis
Bipolar disorder type 2
Formulation for diagnosis and differential diagnosis
As for Mr R, the symptoms clearly showed that he had schizophrenia. The
facts that support the diagnosis were he had disorganized behaviour which he burned
down all the children clothes which he claimed that he was being sihir. He also
broke his mothers bedroom door to take his camcorder and took his mothers angpow
money. Furthermore, he had delusion of grandiosity which he claimed that his father
was King Abdullah and he had RM70 billion in his bank account. Moreover, he also
experienced auditory hallucination which he heard 3 voices talking about what will
happen to his enemies. So, he had the positive symptoms of schizophrenia.
Furthermore, during mental status examination he cannot tell the similarity between
apple and orange was fruit. Instead he answered, the similarity was round. Besides
that, he had past history of schizophrenia which he had been admitted into Hospital
Bahagia Ulu Kinta for 5 times.
Management
1) Investigations:
a. Full blood count
b. Electrocardiogram
c. Renal profile
d. Random blood sugar
2) Get more history from his parents regarding compliance and stressor
3) Psycho-education for his family
4) Refer him to social welfare worker for him to get a job
5) Plan for home-care.
6) Start on antipsychotic such as Risperidone 1mg BD
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