Mood disorder

Mood disorder29 years oldChinesesinglePresent to outpatient clinic in hospital permai without any companyOn 21/4/2015Working as a watch seller but is on unpaid leave for a weekHistory was taken from patient itself

Presenting complaintDifficulty in sleeping for past 2 weeksHistory of presenting complaintUnable to sleep without sleeping pillAble to sleep for 5-6hours even with sleeping pillNormal sleeping pattern: Try various methods to try sleeping includes No hallucination or delusions

Past psychiatric history2010- 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 weekFebruary 2015- visit KK due to similar episode, all investigations came back to be normalMarch 2015-seek help from psychiatrist again due to recurrent episode of panic attack No admissionNo history of self harm/ suicidal attempts

Past medical historyNoneDrug history 2010-Mirtazapine 15mg half tablets OD for a weekFeb 2015(KK)- diazepam 1mg PRNMarch 2015(psychiatrist)- Mirtazapine 15mg half tablets OD for 4 days, stop after feeling better No known drug allergyFamily history Father passed away at the age of 48 years old due to heart failureMother is 68 years old, having diabetes, hypertension and chronic kidney disease, on dialysis 3 times per week No siblings Cousin is diagnosed depressive disorderPersonal HistoryBirth 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 RM2.5kPsychosexual-have been in a relationship for 2 times, no history of sexual assault.1st gf- separated due to financial instability. 2nd gf- separated at September due to long distance relationship and this upset him. He is still hoping to get back together

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

No smokingForensic HistorynonePremorbid HistoryIntrovert Friendly to friends He is a budhist

Mental State ExaminationAppearance and Behaviour Good hygiene, Talkative, good eye contact, easy to build rapport, well well kempt with T-shirt and long pants, calmSpeech fluent, normal rate and volumeMood Patients feels OK. Objectively euthymic. Reactive and appropriate affectThoughts No formal thought disorder. Preoccupation theme: his health conditionPerception patient denied any experience of hallucinationCognitive function appeared alert, orientated in time, place, person, attention and concentration appeared intact, patient could recall 3 objectsInsight aware of his condition and ready to accept treatment