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Mood disorder

29 years old
Chinese
single
Present to outpatient clinic in hospital permai without
any company
On 21/4/2015
Working as a watch seller but is on unpaid leave for a
week
History was taken from patient itself

Presenting complaint
Difficulty in sleeping for past 2 weeks

History of presenting complaint


Unable to sleep without sleeping pill
Able to sleep for 5-6hours even with sleeping pill
Normal sleeping pattern:
Try various methods to try sleeping includes
No hallucination or delusions

Past psychiatric history


2010- 1st episode of panic attack and seek help from
cardiologist, test return to be normal and was referred
to a psychiatrist. He was on medication for a 1 week
February 2015- visit KK due to similar episode, all
investigations came back to be normal
March 2015-seek help from psychiatrist again due to
recurrent episode of panic attack
No admission
No history of self harm/ suicidal attempts

Past medical history


None

Drug history
2010-Mirtazapine 15mg half tablets OD for a week
Feb 2015(KK)- diazepam 1mg PRN
March 2015(psychiatrist)- Mirtazapine 15mg half tablets
OD for 4 days, stop after feeling better
No known drug allergy

Family history
Father passed away at the age of 48 years old due to
heart failure
Mother is 68 years old, having diabetes, hypertension
and chronic kidney disease, on dialysis 3 times per
week
No siblings
Cousin is diagnosed depressive disorder

Personal History
Birth and childhood- vaginal delivery with no developmental problems.
He moved to stay with his uncle from 3-7 years old as his parents need
to work, he was happy and no history of abuse. His parents visit him
once a week.
Education- good relationship with friends and teacher in school.
Complete secondary level education
Employment- first job at the age of 18 years old(father passed away and
he became the main support in the family) as a watch seller until now.
Current salary RM2.5k
Psychosexual-have been in a relationship for 2 times, no history of
sexual assault.1st gf- separated due to financial instability. 2nd gfseparated at September due to long distance relationship and this upset
him. He is still hoping to get back together

Social History
December 2014- accompany mother for dialysis thrice a
week, no time for self
Poor relationship with colleagues,unable to fit in
No financial dept
No smoking

Forensic History
none

Premorbid History
Introvert
Friendly to friends
He is a budhist

Mental State Examination


Appearance and Behaviour
Good hygiene, Talkative, good eye contact, easy to build rapport,
well
well kempt with T-shirt and long pants, calm
Speech
fluent, normal rate and volume
Mood
Patients feels OK. Objectively euthymic. Reactive and appropriate
affect

Thoughts
No formal thought disorder. Preoccupation theme: his
health condition
Perception
patient denied any experience of hallucination
Cognitive function
appeared alert, orientated in time, place, person,
attention and concentration appeared intact, patient could
recall 3 objects
Insight
aware of his condition and ready to accept treatment