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Deipan - 20UMB03886 - Psychiatry CWU 1
Deipan - 20UMB03886 - Psychiatry CWU 1
Deipan - 20UMB03886 - Psychiatry CWU 1
CLINICAL CASE
Chief Complaint
Ms. R is a 27-year-old, Indian lady who was admitted 5 days ago due to suicidal attempt
where she slashed herself on her left wrist with a knife at her home. She was well until she
started having symptoms such as feeling depressed for the last two months after her first child
passed away. Immediately after the incident, Ms. R felt depressed every day about her child’s
death and excessively guilty. As time passed, she became more and more depressed and guilty
and throughout this period, she stayed at home in her room every day and avoided interacting
with other people. She had loss of energy and felt fatigued every day and spent most of her time
at home lying on her bed and being fed by her husband as she did not have the energy to eat and
had loss of appetite. She also complained of having difficulty sleeping for almost every day
where she only managed to sleep 3 to 4 hours a day and some occasions where she could not get
any sleep which is not enough for her as she used to sleep around 8 hours a day.
Throughout this time, Ms. R also had recurrent suicidal ideation but did not have a
specific plan on how she wants to commit suicide. She also did not have any suicidal attempts
until 5 days ago when she was admitted.
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On the day of admission, Ms. R was alone at home. Ms. R wanted to end her life because
of the persistent sadness and guiltiness that she felt. Once Ms. R’s husband left to run errands,
she proceeded to slash herself with the knife that she used at home. Her husband returned home
to find her on the kitchen floor, and she was drowsy. At the emergency department in Hospital
Kuala Lumpur, Ms. R was then admitted to the psychiatry ward due to suicidal attempt.
Otherwise, Ms. R denied having any loss of interest in her hobbies, difficulty
concentrating or self-harm. She also denied having manic symptoms such as decreased need for
sleep, racing thoughts, distractibility, increase in goal-directed activity, talkativeness and
excessive involvement in activities that have a high potential for painful consequences. She did
not experience any hallucinations, delusions of grandiosity, persecutory delusion, or delusion of
control as well as any disorganized behavior. She also denied having anxiety, palpitations,
shortness of breath or restlessness. She denied having symptoms of hypothyroidism such as
constipation, cold intolerance, bradycardia, hair loss or irregular menstrual cycle.
Ms. R does not have any underlying diseases such as diabetes, dyslipidemia, or
hypertension. She also does not have any past surgical history. She had an admission for labor in
2022.
Ms. R is not under any medication and does not take any traditional herbs or
supplements. She does not have any drug or food allergies.
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Family History
Ms. R is the 2nd and youngest child in her family. Her are both well and healthy. There is
no history of mental illness in her family such as major depressive disorder, bipolar disorder,
schizophrenia, or other mental illnesses. Ms. R is unsure if anyone had similar symptoms as. Her
elder brother is also healthy with no known medical illnesses. Ms. R had a daughter who passed
away two months ago at the age of 1 year old.
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Social History
Mr. R lives in an apartment in Jalan Ipoh with her husband. She does not work and is a
housewife. She does not smoke, drink alcohol, or take any illicit drugs. Ms. R is a Hindu. She
walks around her apartment complex 3 times per week.
Systemic Review
No night sweats
No nausea
No vomiting
No dizziness
No chest pains
No arrythmia
No orthopnoea
No pitting oedema
No wheezing
No cough
No nasal discharge
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Gastrointestinal system No gum bleeding
No oral ulcers
No dysentery
No abdominal pain
No diarrhoea
No haematuria
No foul-smelling urine
No blurred vision
No fitting
No numbness
No voice changes
No excessive sweating
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MENTAL STATE EXAMINATION (MSE)
Appearance
Ms. R appeared as a young Indian lady in her late 20s with medium build. She has long wavy
hair which is tied into a ponytail. She was dressed in hospital attire with fair hygiene.
Throughout the interview, she appeared calm and was cooperative while able to maintain good
eye contact. There was no aggressive or hostile behaviour and no hallucinatory behaviour as
well.
Speech
Ms. R spoke in Tamil with slow speed and slow response to questions however had normal
tone and volume. She was not talkative. Her speech was coherent and relevant.
Ms. R wanted to go home and did not want to stay any longer in the psychiatric ward. She also
had suicidal ideations. Her continuity of thought was relevant. She denied hallucinations.
Cognitive Assessment
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Ms. R was able to name the prime minister of Malaysia.
Abstract Thinking
Ms. R’s abstract thinking was intact as she could categorize apples and oranges as types of
fruits.
Insight
Ms. R had good insight. Ms. R knows exactly what mental illness she has. She is committed to
be compliant to her medications.
Judgement
Ms. R has good judgement as when given a scenario of being caught in a building on fire, she
would get herself out and call for help
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PHYSICAL EXAMINATION
Anthropometric Measurement
Height: 157 cm
Weight: 54 kg
BMI: 21.9 kg/m2 (Normal)
Vital Signs
General Examination
Ms. R was sitting comfortably on the bed with no signs of anxiousness. She is conscious,
alert and well oriented. There were no nail changes such as nicotine staining or finger clubbing
and no fine tremors noted. The capillary refill time was less than 2 seconds. There were linear
scars resembling slash marks on her left wrist. The face was symmetrical with no dysmorphic
features. There was no neck swelling and no lymph node enlargement.
Cardiovascular Examination(unremarkable)
The carotid pulse was palpable with no thrills bilaterally. Apex beat was palpable at the
left 5th intercostal space, mid-clavicular line. There were no thrills palpable and no left
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parasternal heave. First and second heart sounds were heard with no murmur and no additional
sound.
Respiratory Examination(unremarkable)
Ms. R’s chest was symmetrical and moved with respiration. There was no tracheal
deviation and no tenderness on the anterior and posterior chest. On percussion, there was
resonance all over the chest with hepatic and cardiac dullness. On auscultation, there was normal
vesicular breathing with no added sounds.
Abdominal Examination(unremarkable)
The abdomen was flat and moved with respiration. There was no flank fullness. There
was. There were no other scars, surgical wound, striae, prominent veins, or abnormal pulsation
seen. On palpation, there was no tenderness or abnormal mass felt. There was no
hepatosplenomegaly and kidneys were not ballotable. On percussion, Traube’s space was
resonant. Shifting dullness and fluid thrill were negative. On auscultation, bowel sounds were
normal. There were no aortic bruit, renal bruit, hepatic bruit and splenic bruit heard.
Neurological Examination(unremarkable)
Ms. R’s mental status was intact and was able to understand and answer questions
logically. There was no slurring of speech. Ms. R was able to understand and follow commands.
There were no scars, muscle wasting, involuntary movement or fasciculation of the upper and
lower limbs noted. On neuromuscular examination, muscle tone was normal on both upper and
lower limbs. The power is 5/5 bilaterally for both upper and lower limbs. All reflexes were
normal. Sensation of upper and lower limbs were intact, and gait was normal. All cranial nerves
were intact.
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Musculoskeletal Examination(unremarkable)
SUMMARY OF CASE
Ms. R, a 27-year-old, Indian lady was admitted due to suicide attempt. She was well until
2 months ago after her first child passed away, where she started to have depressed mood every
day. Her depressed mood was associated with feelings of excessive guilt, fatigue or loss of
energy, loss of appetite and insomnia. Throughout this period, she also had recurrent suicidal
ideations but did not have any specific plan on how to commit suicide. Otherwise, Ms. R denied
having loss of interest in her hobbies and difficulty concentrating. She also denied any history of
manic symptoms, anxiety symptoms or symptoms of hypothyroidism. She also did not have any
hallucinations, delusions of grandiosity, persecutory delusion, or delusion of control as well as
any disorganized behaviour. On MSE, Ms. R spoke in slow speed with slow response to
questions. Throughout the interview, she felt sad and had suicidal ideations. She had ongoing
auditory hallucinations during the interview. She also had good insight towards her condition and
good judgement. On physical examination, there was multiple slash marks on her left wrist.
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PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
1. Bipolar disorder in major depressive episode
Supporting evidence
Depressed mood for 2 months
Loss of appetite
Insomnia
Fatigue and loss of energy
Feeling of excessive guilt
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Recurrent suicidal ideation without a specific plan and suicide attempt
MSE: psychomotor retardation, auditory hallucinations, suicidal ideations
PE: slash wounds seen on her left wrist
Evidence against
No history of manic symptoms
2. Schizoaffective disorder
Supporting evidence
Major depressive episode for 2 months
Presence of negative symptom such as asociality
Evidence against
No persecutory delusion, grandiose delusion or delusion of control
No hallucinations
No disorganized speech
No disorganized behaviour
3. Hypothyroidism
Supporting evidence
Depressed mood
Fatigue
Loss of appetite
Evidence against
No constipation
No cold intolerance
No bradycardia
No hair loss
No irregular menstrual cycle
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INVESTIGATIONS
Biological Investigations
Investigation Indication
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1. Full blood count
Reference
Blood Components Results Interpretation
Range
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Parameters Reference Range Results Interpretation
Psychological Investigations
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Investigation Indication
Beck suicide intent scale To assess the level of suicidal intent or the intensity
(BSIS) of the attempter's wish to die at the time of the
attempt.
Social Investigation
Investigation Indication
Collaborative history from To have a more detailed history of Ms. R’s behaviour
family members at home, socioeconomic status, and financial support.
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MANAGEMENT
I would approach this case through the biopsychosocial approach. According to Clinical
Practice Guidelines (CPG) Malaysia for the management of MDD, the general principles of
management of MDD are as follows:
to relieve symptoms
to reduce the morbidity and disability
to limit risks of self-harm and fatality
Criteria of admission of patients with MDD are indicated when there is risk of harm to self,
psychotic symptoms, inability to care for self, lack of impulse control and danger to others. In
this case, admission is indicated as Ms. R was at risk of harming herself. Admission can be
voluntary or involuntary according to the Mental Health Act (2001).
Acute Phase
Psychosocial intervention and psychotherapy are offered during this phase. Pharmacotherapy is
also offered with the aim of preventing relapse and recurrence. The duration of maintenance
phase treatment is between 6 to 9 months after remission. Maintenance phase treatment must be
considered for 2 years or more if the risk of relapse and remission is high.
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Risks of relapse and recurrence of MDD:
Biological Approach
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Psychosocial Approach
Psychoeducation
Psychotherapy
CBT focuses on the impact a person’s unhelpful thoughts have on the current behavior and
functioning, through cognitive restructuring and behavioural approach.
IPT focuses on interpersonal relationship to help patients improve their social support network
and manage interpersonal distress that may be associated with the depression.
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DISCUSSION
Introduction
Epidemiology
MDD is more common in female with a lifetime prevalence of 10-20% and the peak age of
onset is more common in 3rd decade of life.
Aetiology
Biological factors
o Genetic factors
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o Increased production of stress hormones (e.g., dysfunction of the hypothalamic-
pituitary-adrenal axis)
Diagnostic Criteria
To diagnose MDD, according to the DSM-5, the following criterias must be met:
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In this case, Ms. R fulfils criteria A whereby for the past 2 months, she has depressed mood
most of the day, nearly every day, loss of appetite, insomnia, psychomotor retardation, fatigue or
loss of energy, feelings of excessive guilt and suicide attempt and recurrent suicidal ideation. She
also fulfils criteria B whereby there was significant impairment in her social functioning as she
stayed in her room most of the day avoiding interaction with other people. Ms. R also fulfils
criteria C whereby she denied any substance abuse, or any signs and symptoms of
hypothyroidism. Criteria D is fulfilled as Ms. R denied symptoms of psychosis. She also did not
have disorganized behaviour or speech. Criteria E is also fulfilled as she did not have any manic
or hypomanic episode before.
Ms. R fulfils all criteria, she can be given the diagnosis of major depressive disorder.
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Investigation
Bio
Psycho
Screening tools can be used to screen for depression and assess the severity of
depression. The common tools used in Malaysia for screening of depression are Beck Depression
Inventory (BDI), Depression, Anxiety and Stress Scale (DASS), Patient Health Questionnaire-9
(PHQ-9), and Hospital Anxiety Depression Scale (HADS). Another tool that has been validated
locally is the Whooley Questions which is a shorter tool used to screen for depression. The
Whooley Questions may be considered in people who may have depression particularly in those
with a past history of depression or a chronic physical health problem with associated functional
impairment.
Social
It is important to investigate the social factors that may be impacting the patient’s
depression. This involves assessment of the patient’s social support network and the quality of
their relationships with family, friends, and significant others. It is also important to identify any
recent or past significant life events, such as trauma, loss, or major changes, that may be
contributing to the development of depression. We must also assess environmental factors and
carry out evaluation of the patient’s living situation, work environment, socioeconomic status,
and any other contextual factors that may impact their mental health.
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Treatment (As discussed above)
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REFERENCES
American Psychiatry Association. (2016). Desk reference to the diagnostic criteria from DSM-5.
5th ed. Arlington: American Psychiatric Association.
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