En. H Psy

KURSUS DIPLOMA PEMBANTU PERUBATAN PSYCHIATRIC CASE CLERKING Patient’s Biodata: Name : MUHAMMAD HASHIM BIN JUNID I/C No.: 390911 – 05 – 5149 Date of Birth:

11.09.1939

Religion: ISLAM

Sex: MALE

.

Age: …………. Race: MALAY

Marital Status: MARRIED

Occupation: RETIRED PENEROKA FELDA

.

Present Address: NO 41, PERINGKAT 4, FELDA BUKIT ROKAN, GEMENCHEH Telephone: (H) ……………………………… (H/P) ……………………..………………… Name of Next of Kin: ……………………………….. I/C No.: …………..………………… Relationship: ………………………………………. Occupation: …………….…………… Address: …………………………………………………………………………………….… …………………………………………………………………………………………………. Telephone: (H) ……………………………… (H/P) ……………………………………… Admission Status:

Voluntary Temporary Compulsory

Number of previous admission (If any): …………………………………………………… Registration Number (If any): ……………………………………………………………… ADMISSION:

DISCHARGE:

Date: …………………………….

Date: ………………………

Time: ……………………………

Time: ………………………

REFERRAL SOURCE: (Referral forms attached) Language Spoken In History Taking: CHIEF COMPLAINTS:

-

Referred case from Emergency and Trauma Department Hospital Tuanku Jaafar Seremban. Used Form 5 Malay

-

Abnormal behavior x 1 year Aggressive behavior x 3/7

HISTORY OF PRESENT ILLNESS:

No known present illness

HISTORY FROM RELATIVES: (State relationship and name of informant) List Complaints, type of onset, duration, precipitating factors, relieving factors, associate experience.

According to his daughter, Muhammad Kamal

ABILITY FOR WORK:

Patient is able to work and obey to command

SLEEP PATTERN:

Unable to sleep well at night

APPETITE:

Reduced appetite

TOLET HABITS:

BO and PU had no problem

TREATMENT FROM WHATEVER SOURCES:

Private psychiatrist from Hospital Colombia Asia

Types of Treatment Given:

Oral medication but patient refused the medication from hospital.

FAMILY HISTORY: Father/Mother: Siblings/Other Relatives: Ages and Occupation: Emotional Relationship: Economic Status/Social Standing: Mental Illness or Other Diseases In Family: PERSONAL HISTORY: Birth/Milestone: Childhood: Neurotic Problems and Health In Childhood: School: Academic Record: Activities/Social Ability: Examination/Grades and Dates: Work Record: List Jobs/Salaries: Reasons for Changes: Sexual Experience: Menstrual History: Marriage(s): Age, Occupation and Personality of Spouse: Sexual Practice/Children: List Ages and Occupation: Miscarriages/Social-Cultural Background: Present Home: Total Family Income: Friends/Social-Cultural Background: Religious Affiliations: Smoking/Drinking/Drugs:

No problem None -

Work as peneroka felda Peneroka Felda – RM3,000 married

Patient has 7 children. Stay with wife at Bukit Rokan RM3,000 Socialize with others and make many friends Muslim - Quit smoking many years ago - Does not consume alcoholic - Denies any substance or drug

PREMORBID PERSONLITY: (Preferably From Relatives Or Friends) Previous Medical History:

Previous Psychiatry History:

none

GENERAL APPEARANCE AND BEHAVIOUR: General Impression: State of Consciousness: Physical Appearance: Manner of Dressing/Cleanliness: Facial Expression and Posture: Reactivity to Surrounding: Mannerisms: Ability to Co-operate: TALK: Languages/Dialect Spoken: Amount of Talk: Rational/Relevance/Coheren ce: Flights of Ideas: Looseness or Clang Association: Thought Block: Circumstantiality: Neologies (Quote Speech Samples): Pressure of Speech: Word Salad: MOODS: Mood State: Affective Response: Consistency of Mood: Withdrawal: THOUGHT CONTENTS: Delusion & Misinterpretations: Feelings of Influence: Feelings of Passivity: Depersonalizations: Hypochondrias: Hallucinations: Preoccupation: Obsessions/Phobias: Over Determined Ideas: Suicidal Thoughts: Repetitive Dreams: (Described these in details) ORIENTATION: Place: Time: Person:

- Malay man conscious -

Can manage himself well Good hygiene

Good eye contact Good mannered Able to cooperate Malay Average Relevant and coherent None None None None No pressured None Euthymic Good None Patient has persecutory delusion and denies any perceptional

None None Not suicidal

Patient is able answer and recognize where Patient know what time is it Patient can recognize people well

MEMORY: Remote Memory: Recent Memory: Immediate Memory: Confabulation: Five Minutes Memory Test: INFORMATION & VOCABULARY: Estimate Intelligence Level: ABSTRACTION: Proverbs Test: ATTENTION & CONCENTRATION: Distractibility: Serial Seven Test:

Good Good Good Good Patient can remember well

Unable to complete serial Seven test, patient claimed that his mathematic calculation is poor.

Digit Span: JUDGEMENT: INSIGHT:

No insight

PHYSICAL EXAMINATION: GENERAL: Temp: Pulse Rate: Resp. Rate: B/P: CARDIO-VASCULAR SYSTEM:

36.4 C 85 20 110/72 mm/hg - Normal heart beat rate - No abnormal sound found during auscultation - No murmur

RESPIRATORY SYSTEM:

-

Chest expand normal, No abnormal lung sound produce Breathe well

ABDOMEN:

-

Normal No pain or organomegaly during palpation

CENTRAL NERVOUS SYSTEM:

SUMMARY OF PHYSICAL FINDINGS:

List chief clinical features below:

DIAGNOSIS: DIFFERENTIAL DIAGNOSIS: TREATMENT PLAN:

LAPORAN REFLEKTIF: (Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah diperolehi daripada pengkajian kes ini) Pengurusan kes:

Baik Memuaskan Lemah

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini: ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ...................................................................................................................................... ....................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................

KURSUS DIPLOMA PEMBANTU PERUBATAN FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING Nama Pelatih: …………………………………………

No. Matrik: ………….……….

Tahun: …… Semester: ……… Kawasan Penempatan: ...………………………… Bil. 1 2

3

4

5 6 7

8

Perkara Biodata pesakit Riwayat Pesakit: 2.1 Aduan Utama 2.2 Sejarah Penyakit Kini 2.3 Sejarah Dari Ahli Keluarga 2.4 Sejarah Keluarga 2.5 Sejarah Personal (Lain2 yang berkenaan) Penilaian Staus Mental: 3.1 Keadaan Am & Tingkah Laku 3.2 Percakapan 3.3 Mood 3.4 Pemikiran 3.5 Orientasi 3.6 Memori 3.7 Information,Vocabulary & Abstraction 3.8 Attention & Concentration 3.9 Judgement & Insight Pemeriksaan Fizikal: 4.1 Pemeriksaan Am 4.2 Tanda-tanda Vital 4.3 Kepala & E/ENT 4.4 Dada (Jantung) 4.5 Dada (Paru-paru) 4.6 Abdomen 4.7 Sistem Saraf 4.8 Anggota Atas & Bawah 4.9 Lain-lain (seperti genitalia & rektum, dll) Ringkasan Penemuan Klinikal Diagnosis: 6.1 Diagnosis Sementara 6.2 Diagnosis Perbezaan Pengurusan: 7.1 Pengendalian awal 7.2 Ubat-ubatan 7.3 Penjagaan kejururawatan Laporan reflektif JUMLAH

Tandatangan Pemeriksa

Wajaran 5

25

25

10

5 5

20 5 100

: ……………………………….……………

Skor

Catatan

Nama

: …………………………….………………

Tarikh

: ……………………………………………

KURSUS DIPLOMA PEMBANTU PERUBATAN SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION Nama Pelatih: …………………………………………

No. Matrik: ………….………...

Tahun: …… Semester: ……… Kawasan Penempatan: ...………………………… Bil.

Perkara

Wajaran

1

Pembentangan biodata pesakit yang tepat dan lengkap

2

Pembentangan riwayat pesakit yang lengkap

3

4

5

6

Melakukan penilaian status mental yang lengkap dan relevan dengan tepat Melakukan pemeriksaan fizikal yang lengkap dan relevan dengan betul Cadangan diagnosis & diagnosis perbezaan yang tepat Pembentangan pengurusan pesakit yang tepat dan lengkap JUMLAH

PELAKSANAAN Memuas Baik Lemah kan

1 2

3

1 1

2 10

Skor: …….........… x 100% = ..........................% 10 Tandatangan Pemeriksa

: ……………………………….……………

Nama

: …………………………….………………

Tarikh

: ……………………………………………

Skor

Catatan