Psychiatric Case Clerking :)

REFERRAL SOURCE: (Referral forms attached)

- Referred case from Hospital Kota Tinggi Johor - Used form 3 and 4 with police referral letter ( Pol 57)

Language Spoken In History Taking: CHIEF COMPLAINTS:

- Malay

HISTORY OF PRESENT ILLNESS:

- 42 years old Malay male - Known complain of ( k/c/o ) schizophrenia. He was ill since 30 years old - Defaulted treatment - Patient denies having hallucination - Patient claim at home he didn’t compliance to medication - Had on off taking medicine - Patient claim always forget to take medicine and unsure either he compliance to injection or not.

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

- According to his father, Encik Ibrahim bin Haji Samat

ABILITY FOR WORK:

- Patient is able to work and obey to command

SLEEP PATTERN: APPETITE:

- Patient admit he has poor sleep and only can sleep 5 hour per day - Patient has good appetite

TOLET HABITS:

- BO and PU had no problem

TREATMENT FROM WHATEVER SOURCES:

- Was admit in Hospital Kota Tinggi due to MVA ( Car vs Motorcycle ) since 8 years ago

Types of Treatment Given:

- Toilet & Suture and nursing care

- Aggressive behavior with psychotic symptoms since 1/12 ago - Have auditory hallucination and visual hallucination - Become worst since 1/52 before pre admission

- Patient was brought in by Bilik Daftar Masuk ( BDM ) staff via walking as patient was relaps schizophrenia - Already admitted at Hospital Kota Tinggi before for 1/52 but ran away after been told to admit to Hospital Permai - After been caught again, he was sent to Hospital Permai due to his aggressive behavior since 1/12 ago - In this 1/12, he was learning something new. He was used kitchen knife,burn it until red with some religion word like “ wali-wali keramat” repetitively. Then his mother was afraid and call the police.

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:

- Is good with family members - Good economic, family was in middle class stage - Good social, all family members can socialize with others - Mother and his young brother has mental illness and never get treatment - SVD and no problem during delivered - No problems - None - Sek. Keb. Bandar Mas, Kota Tinggi - Sek. Men. Keb. Air Tawar , Kota Tinggi - Sijil Rendah Pelajaran ( Form 3 ) - Talkative and have many friends - Failed in SRP in year 1986 - Multiple job at one time after SRP. For example,he work in a factory before he was sick. After his illness was been discovered, he work as a guard. At the beginning, he was good doing his job, not disturbing others ,not harmful, always pray but then become worst and had to admit to Permai again - Worked in factory in year 1990 : ( RM 300 ) - Worked as a guard in year 2011 : ( RM 900 ) - Not suitable for him - His illness becomes worst because not compliance medication - None - Puberty at 12 years old, - Non-married - 42 years old, work as guard - None - None - None - Staying at home with his father and mother in Kota Tinggi, Johor Baharu - RM 3000

Friends/Social-Cultural Background: Religious Affiliations: Smoking/Drinking/Drugs: PREMORBID PERSONLITY: (Preferably From Relatives Or Friends) Previous Medical History:

Previous Psychiatry History:

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:

- Socialize with others and make many friends - Muslim - Smoking 10 stick per day since 17 years old - Denies any recent alcohol intake - Denies any substance or drug

- On ward medical at Hospital Kota Tinggi, Johor due to MVA ( car vs motorcycle ) - Doesn’t remember any treatment given - Multiple injuries including head - Had mental illness since he was 30 years old - Multiple admission to Hospital Permai - Get treatment at home under Community Psychiatry Unit ( CPU )

- Middle age malay man - Wearing hospital attire - Conscious - Short black hair - Asthenic body - Can manage himself well - Good hygiene - Patient happy and always in a good mood - Good eye contact - Good mannered - Able to cooperate - Bahasa Melayu - Very talkative - Good - Had many idea - Poor - None - None - None - No pressured - None - Showed his feeling well when talking - Not elated affects - Good - None - None

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:

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: Digit Span: JUDGEMENT: INSIGHT: PHYSICAL EXAMINATION: GENERAL:

- None - None - None +AH : - Heard man’s voice talking to him - Patient claims that the voice was ‘agong’ and threatened him usually hear the voice when patient is alone +VH : - Saw certifieate award on his hand - Patient claim that the certificate award was very big and belongs to his friends - He said he saw ‘ Sultan Arab ‘ and he ask for forgiveness for what are have done before - Can see ahli-ahli sufi - None - Patient was obsess with knife, whenever he got the knife he feel like he want to kill people - None - Not suicidal - None - Patient is able answer and recognize where - Patient know what time is it - Patient can recognize people well

- Good - Good - Good - Good - Patient can remember well

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:

- Normal - Gait and reflexes score 5/5

SUMMARY OF PHYSICAL FINDINGS:

List chief clinical features below:

DIAGNOSIS:

- Schizophrenia

DIFFERENTIAL DIAGNOSIS: TREATMENT PLAN:

Admit to blossom C Tab Vallium 10 mg prn 1 to 1 nursing care I/M modecate 37.5 mg two 2/54

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

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5 6 7

8

Perkara Wajaran Biodata pesakit 5 Riwayat Pesakit: 2.1 Aduan Utama 2.2 Sejarah Penyakit Kini 2.3 Sejarah Dari Ahli Keluarga 25 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 25 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) 10 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 5 Diagnosis: 6.1 Diagnosis Sementara 5 6.2 Diagnosis Perbezaan Pengurusan: 7.1 Pengendalian awal 20 7.2 Ubat-ubatan 7.3 Penjagaan kejururawatan Laporan reflektif 5 JUMLAH 100

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

No. Matrik: ………….………...

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

Wajara n

Perkara

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Pembentangan biodata pesakit yang tepat dan lengkap

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Pembentangan riwayat pesakit yang lengkap

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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 Memua Lema Baik skan h

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2 10

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

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