Case Presentation

Group 6
- Sukhveer SIngh A/L Rajindar Singh (012021100172)
- Hemanand Naidu A/L Anbhananthan (012021100171)
- Sabanathan A/L Sathappan (012021100071)
- Aravendganesh A/L Ramakrishanan (012021100120)
 2

Patient Details
Name: Mr A
Hospital: Hospital Tengku Ampuan Rahimah (HTAR)
Registration Number: 23744
Date of Clerking: 22/01/2025
Age: 18 years
Gender: Male
Race: Malay
Religion: Islam
Occupation: Student
 3

Chief Complaint
A one-week history of agitation, paranoid
delusions, and auditory hallucinations, with
escalating aggression over the past three
days.
 4

History of Presenting Illness

Mr. A, an 18-year-old male, was brought to the Emergency Department at HTAR by his
parents after a one-week history of behavioral changes, including aggression, paranoia,
and auditory hallucinations, which escalated over the past three days.

His symptoms include:

Paranoid Delusions:

● Mr. A frequently expressed distrust toward family members and close friends.
● He believed strangers were “spies” following him and plotting against him.
● Accused his parents of betrayal and tampering with his food.
 5

History of Presenting Illness

Auditory Hallucinations:

● Reports hearing male voices that insult and threaten him.

● Voices often commented on his actions or warned him of danger.

Aggressive Behavior:

● Shouting at family members and throwing household items.

● Confrontational in public, attempting to approach people he believed were following
him.
● Isolated himself in his room for long hours, refusing to engage with anyone.
 6

History of Presenting Illness

Over the past three days, his symptoms worsened significantly:

1. He became more irritable and hypervigilant, pacing around the house and frequently
checking windows for "spies."
2. He avoided meals, stating they were poisoned, and showed a notable decline in
personal hygiene.
3. His sleep was severely disrupted, with difficulty falling asleep and frequent
awakenings, appearing anxious and visibly distressed.

His parents linked these symptoms to Mr. Aʼs methamphetamine use, which began
approximately two months ago. He admitted to using the substance regularly with friends,
primarily in social gatherings, and also reported experimenting with cannabis occasionally.
 7

History of Presenting Illness

● Recent Behavioral Changes:
○ Gradual social withdrawal over the past few months.
○ Episodes of intense energy and reckless behavior, including talking excessively.
○ Dropped out of school six months ago, citing stress and inability to concentrate.

Mr. A was described as a sociable and obedient young man prior to his substance use. His
parents reported no prior psychiatric or medical history and denied any past episodes of
psychosis or unusual behavior.

Currently, Mr. A denies any insight into his condition, firmly believing that his delusions and
hallucinations are real and attributing them to external conspiracies rather than his
methamphetamine use.
 8

Past Psychiatry History

A has no documented history of psychiatric disorders prior to his current presentation.
However, his parents report subtle behavioral changes over the past year iincluding:

● Social Withdrawal: Gradual isolation from family and friends, preferring to spend
time alone or with peers involved in substance use.
● Decline in Academic Performance: Struggled with concentration and focus,
eventually dropping out of school six months ago due to feelings of stress and failure.
● Mood and Behavior Changes: Episodes of irritability and reckless behavior,
including impulsive decisions and increased conflict with family members.
● Substance Use as a Trigger: Methamphetamine use began two months ago,
coinciding with the onset of psychotic symptoms. Occasional cannabis use was also
reported in earlier years but without significant impact on his mental state until now.
 9

Past Medical, Drug & Allergy History

No Known Medical History

Current Medications: None.

Drug Allergies: None known.

Substance Use History:

● Methamphetamine: Regular use over the past two months, particularly in social
settings.
● Cannabis: Occasional use reported.
● No history of alcohol or tobacco use
 10

Family History
● No known psychiatric or substance-related disorders in immediate family members.
● Father has hypertension; mother is healthy.
● Two younger siblings, both healthy.
 11

Social History
● Mr. A is the eldest of three siblings and resides with his parents in Klang.
● He recently dropped out of school, citing academic stress and difficulty
concentrating.
● Frequently associates with peers known for substance use, often returning home
late.
● His relationship with family has become strained due to behavioral changes.
● Denies smoking or alcohol use but admits to experimenting with drugs under peer
influence.
 12

Mental & Physical

State Examination
Mental State Examination
● General Appearance and Behaviour
○ He appears appropriate for his age. He was in hospital attire. His attire was
disheveled, with poor grooming and unkempt hair. He had a tense posture
while seated on a chair. He had no abnormal movement. His eye contact is
poor. He occasionally glances to one side as though responding to an
unseen stimuli. He was cooperative thorough the interview and a good rapport
was established.
● Speech
○ He spoke fluently in both Bahasa Melayu. His speech was relevant and
coherent. His speech was loud, pressured, and tangential. Frequently
references delusional themes.
● Affect and Mood
○ His mood was anxious throughout clerking. The affect was appropriate and
congruent with his stated mood.
● Perception
○ He has auditory hallucinations (second person)
○ No visual or tactile hallucinations
○ There are no illusions, derealization and depersonalisation
● Thought
○ He has paranoid delusions
○ He believes his family are tampering with his food.
○ He believes strangers are spies sent to follow him.
● Cognitive Function
○ Orientation
■ He was alert, conscious and well oriented to time, place and person.
○ Memory
■ Immediate: Intact (able to recall digit span 4038)
■ Recent: Intact ( able to remember who sent him to hospital)
■ Remote: Intact ( able to remember when is his birthday)
● Attention and Concentration
○ He is easily distracted by external stimuli. Attention span is short.
○ Able to spell DUNIA forward and backward
○ Abstract thinking
○ Knows the meaning of ‘kaki bangkuʼ
○ General knowledge
○ Knows the current prime minister of Malaysia
● Judgement
○ Has good judgement
○ When asked regarding if his house is on fire, he said heʼll call the fire
department.
● Insight
○ His insight into his condition is poor
○ Awareness:He is aware as to why he has been admitted to ward but he
doesnʼt think he is sick
○ Attribution:He is unable to attribute the cause of her symptoms
○ Willingness:He is willing to take the medication if it is good for him but he
still has an idea that people are trying to harm him with that medication.
Physical Examination
Patient was seated comfortably and appeared well-nourished. He was conscious, alert
and well oriented to time, place, and person. He was cooperative and under no respiratory
distress or discomfort. He had a medium build with good nutritional and hydration status.

Pulse rate 75 beats per minute (regular rhythm, good volume,

and normal character)

Respiratory rate 20 breaths per min (normal)

Blood pressure 115/79 mmHg (normal)

Temperature 36.7 ºC (afebrile)

spO2 98% in room air

General Examination
Hands - His hands were warm and dry upon touch Neck - Trachea is not deviated.
- Capillary refill time < 2 seconds - No swelling
- No palmar pallor - Lymph nodes were not enlarged.
- No palmar erythema - JVP was not raised
- No peripheral cyanosis

Eyes - No subconjunctival pallor Lower limbs - No pitting edema

- No yellowish discolouration of jaundice - No dilated veins
- No corneal arcus - No leg ulcers
- No xanthelasma
- No sunken eyes

Mouth - No angular stomatitis

- Oral hygiene was good.
- No dental carries and oral ulcers were seen.
- Lips were moist and pink.
- No central cyanosis
Systemic Examination
CARDIOVASCULAR SYSTEM

Inspection:

There were no surgical scars on the chest. There was also no visible ventricular pulse or dilated veins. The
precordium was in normal shape and there was no bulging.

Palpation:

Apex beat was palpable at the 5th intercostal space to the left of the midclavicular line. No parasternal
heaves or palpable thrills were felt.

Auscultation:

Normal heart sounds, S1 and S2 were heard on all four cardiac regions with no added sounds or murmurs.
RESPIRATORY EXAMINATION

Inspection:

The chest moves symmetrical bilaterally with respiration. There were no surgical scars or dilated veins on the
chest. There were no chest deformities. The patient has no signs of respiratory distress.

Palpation:

Chest expansion was symmetrical on both sides. The trachea was centrally located and was not deviated.

Percussion:

Normal resonance was noted when percussing both lungs which includes the chest wall, supraclavicular
and infraclavicular region.

Auscultation:

The air entry was equal bilaterally on both sides of lungs. Vesicular breath sound was heard with no added
sound. There was no prolonged expiratory phase.
ABDOMINAL EXAMINATION

Inspection:

The shape of the abdomen was normal and symmetrical. There was no abdominal distention. The umbilicus
was centrally located and inverted. There were also no surgical scars, rash, dilated veins, or visible pulsations.
The abdomen moved equally with respiration and the flank was not full.

Palpation:

Upon superficial palpation, all quadrants were soft. There was no tenderness on all quadrants. Upon deep
palpation, there was no palpable mass, The liver and spleen were not palpable. Kidneys were not ballotable.
There was also no rebound tenderness.

Percussion:

All 9 regions were resonant upon percussion. There was no shifting dullness or fluid thrill.

Auscultation:

Normal bowel sounds were heard, and no renal or aortic bruit sounds were heard.
CENTRAL NERVOUS SYSTEM EXAMINATION

Cranial Nerves: All Intact

Motor function: Normal tone and power. No muscle wasting or fasciculation

Reflexes: Intact

Sensory: Intact
 23

Summary

Aravendganesh A/L Ramakrishanan (012021100120)

 24

Summary
Mr. A, an 18-year-old male, presented to the Emergency Department with a one-week history of escalating behavioral changes,
including aggression, paranoia, and auditory hallucinations. Over the past three days, his symptoms worsened significantly, with
increased irritability, hypervigilance, and disrupted sleep. He exhibited paranoid delusions, believing family members were tampering
with his food and that strangers were spies plotting against him. He also reported hearing male voices insulting and threatening him.
His parents noted a gradual decline in his behavior over the past year, including social withdrawal, declining academic performance,
and mood changes, culminating in his dropping out of school six months ago. His symptoms coincided with regular methamphetamine
use over the past two months, with occasional cannabis use reported earlier. He has no prior psychiatric history but has been
associating with peers involved in substance use, leading to strained family relationships.

On mental state examination, Mr. A appeared disheveled and poorly groomed, with poor eye contact and a tense posture. He
occasionally glanced to the side as if responding to unseen stimuli. His speech was loud, pressured, and tangential, frequently
referencing delusional themes. He exhibited auditory hallucinations and paranoid delusions but no visual or tactile hallucinations.
Cognitive functions, including orientation, memory, and general knowledge, were intact, though his attention span was short, and he
was easily distracted. His insight into his condition was poor, as he was unaware of his illness and unable to attribute his symptoms to
a cause, though he was willing to take medication if deemed beneficial. His judgment remained intact, as evidenced by appropriate
responses to hypothetical scenarios. Other physical examination are non significant.
 25

Provisional Diagnosis
DIAGNOSIS
Provisional Diagnosis
Substance Induced Psychosis (Methamphetamine-Related)
Points Supporting
● Presence of symptoms such as hallucinations, delusions, and grossly disorganized
behaviour which all are indicative of psychosis.
● There is history of consuming methamphetamine which is capable of causing
psychosis.
● Since the onset of symptoms, the patientʼs work and social life has deteriorated
significantly compared to how it was prior to onset of symptoms.
● The symptoms are not better explained by another medical or mental condition.
● The symptoms do not occur exclusively during the course of a delirium.
● The symptoms persisted for almost 2 months after taking methamphetamine
 27

Differential Diagnosis

Aravendganesh A/L Ramakrishanan (012021100120)

 28

Differential Diagnosis
Differential diagnosis Point supporting Point against

Primary Psychotic ● Psychotic symptoms (delusions, ● The onset of symptoms is

Disorder (Schizophrenia) hallucinations, and disorganized behavior) closely tied to
are present. methamphetamine use, making
● Social withdrawal, decline in academic substance-induced psychosis
performance, and mood changes over the more likely.
past year could suggest a prodromal phase ● No clear evidence of persistent
of schizophrenia. psychotic symptoms for at least
six months, which is required for
a schizophrenia diagnosis.
 29

Differential Diagnosis Cont.

Differential diagnosis Point supporting Point against

Bipolar Disorder with ● Irritability, aggression, and mood changes ● There is no clear history of
Psychotic Features could suggest a manic or mixed episode with elevated mood, grandiosity, or
psychotic features. other hallmark symptoms of
● Sleep disturbances and hypervigilance may mania.
align with manic symptoms ● Psychotic symptoms are more
consistent with substance use
rather than a mood disorder.
 30

Differential Diagnosis Cont.

Differential diagnosis Point supporting Point against

Delusional Disorder ● Persistent paranoid delusions (e.g., belief ● The presence of auditory
that family is tampering with his food and hallucinations is not typical of
strangers are spies) are present. delusional disorder.
● His delusions are well-systematized and ● The temporal relationship with
non-bizarre. methamphetamine use strongly
suggests a substance-induced
etiology rather than a primary
delusional disorder.
 31

Investigations
 Full Blood Count:
Components Results Normal Range Interpretation

Haemoglobin (g/dL) 14.6 13.0-18.0 Normal

Hematocrit (g/dL) 45 40 - 54 Normal

Platelet count(10^mm^3) 378 150-450 Normal

TWBC (10^3mm^3] 14.3 4.0 - 11.0 Normal

MCV (fl) 85.8 80 - 100 Normal

MCH (pg) 29.1 27 - 32 Normal

MCHC (g/dL) 34.0 32 - 36 Normal

Neutrophils(x 10^9\L) 7.1 2.0 - 8.0 Normal

Lymphocytes (x 10^9/L) 3.4 1.0 - 4.0 Normal

Basophils (%) 0.7 1-2 Normal

Eosinophils (%) 2.2 1-6 Normal

Liver Function Test - To look for liver inflammation

Components Results Normal Range Interpretation

Total protein (g/dL) 72 60 - 80 Normal

Albumin (g/dL) 33 35 - 50 Normal

Globulin (g/dL) 27 20 - 35 Normal

ALP (IU/L) 120 40 - 125 Normal

ALT (IU/L) 12 10 - 50 Normal

AST (IU/L) 18 8 - 33 Normal

Bilirubin (umol/L) 10 3 - 16 Normal

● Urine Drug Screen - Positive for Methamphetamine

● Lipid Profile

Components Resulst Normal Range Interpretation

Cholesterol 3.2 < 5.0 Normal

(mmol/L)

Triglycerides(mmol/ 1.3 0.5 - 2.3 Normal

L)

HDL (mmol/L) 1.1 0.9 - 1.9 Normal

LDL (mmol/L) 0.6 < 2.0 Normal

 35

Proposed Investigations

1. Renal Function Test: Assess baseline kidney function before initiating or adjusting
psychotropic medications.
2. Thyroid Function Test (TFT): Exclude hypothyroidism or hyperthyroidism as a contributor
to psychosis or mood symptoms.
3. Vitamin B12 and Folate Levels: Check for deficiencies that could mimic or exacerbate
psychiatric symptoms.
4. Random Blood Glucose/HbA1c: Screen for diabetes, especially if atypical antipsychotics
are planned.
5. CT of the Brain: Rule out structural brain lesions (e.g., tumors, strokes) or
neurodegenerative conditions that could contribute to psychotic symptoms.
Management
MX Done by Hospital
● Admitted to the ward
● T Diazepam 1mg TDS
● Monitor vital signs
● Continue behavioural charting
● Psychotherapy- CBT
Proposed Management
Supportive care: IV fluids, electrolyte balance, cooling measures.
Psychosocial Interventions:
● Cognitive Behavioral Therapy (CBT): To address cravings and relapse prevention.
● Motivational Interviewing (MI): To enhance commitment to quitting.
● 12-Step Programs/Support Groups: Narcotics Anonymous (NA), group therapy.
Medications:
● Bupropion, Naltrexone, Topiramate (potential benefit in reducing cravings).
● Mirtazapine (may help with sleep and mood stabilization).
Harm Reduction Strategies:
● Safe environments: Supervised detox centers.
● Education: Risks of use
Case Formulation
Factors Biological Psychological Sociological

Predisposing ● No family history of ● Low self esteem ● Peer influence

psychiatric ● Lack of coping ● Gradual social
disorders mechanism for withdrawal
stress

Precipitating ● Regular use of ● Increased stress ● Reduced parental

methamphetamine from academic supervision
failure ● Peers also use
substance

Perpetuating ● Lack of insight ● Ongoing strained

● Paranoia and family dynamics
auditory
hallucination

Protecting ● Young age ● No prior history of ● Parenteral concern

psychiatric and willingness to
disorders seek medical help
Questions?
THANK YOU