You are on page 1of 10

REFERRAL SOURCE: - Referred case from Hospital Kota Tinggi Johor

(Referral forms attached) - Used form 3 and 4 with police referral letter
( Pol 57)

Language Spoken In History - Malay


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

HISTORY OF PRESENT - 42 years old Malay male


ILLNESS: - 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 - According to his father, Encik Ibrahim bin Haji


RELATIVES: Samat
(State relationship and name
of informant)
List Complaints, type of - Patient was brought in by Bilik Daftar Masuk
onset, duration, precipitating ( BDM ) staff via walking as patient was relaps
factors, relieving factors, schizophrenia
associate experience. - 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.

ABILITY FOR WORK: - Patient is able to work and obey to command

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

TOLET HABITS: - BO and PU had no problem

TREATMENT FROM - Was admit in Hospital Kota Tinggi due to MVA ( Car
WHATEVER SOURCES: vs Motorcycle ) since 8 years ago

Types of Treatment Given: - Toilet & Suture and nursing care


FAMILY HISTORY:
Father/Mother:

Siblings/Other Relatives:

Ages and Occupation:

Emotional Relationship: - Is good with family members


Economic Status/Social - Good economic, family was in middle class stage
Standing: - Good social, all family members can socialize with
others
Mental Illness or Other - Mother and his young brother has mental illness
Diseases In Family: and never get treatment
PERSONAL HISTORY:
Birth/Milestone: - SVD and no problem during delivered
Childhood: - No problems
Neurotic Problems and - None
Health In Childhood:
School: - Sek. Keb. Bandar Mas, Kota Tinggi
- Sek. Men. Keb. Air Tawar , Kota Tinggi
Academic Record: - Sijil Rendah Pelajaran ( Form 3 )
Activities/Social Ability: - Talkative and have many friends
Examination/Grades and - Failed in SRP in year 1986
Dates:
Work Record: - 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
List Jobs/Salaries: - Worked in factory in year 1990 : ( RM 300 )
- Worked as a guard in year 2011 : ( RM 900 )
Reasons for Changes: - Not suitable for him
- His illness becomes worst because not compliance
medication
Sexual Experience: - None
Menstrual History: - Puberty at 12 years old,
Marriage(s): - Non-married
Age, Occupation and - 42 years old, work as guard
Personality of Spouse:
Sexual Practice/Children: - None
List Ages and Occupation: - None
Miscarriages/Social-Cultural - None
Background:
Present Home: - Staying at home with his father and mother in Kota
Tinggi, Johor Baharu
Total Family Income: - RM 3000
Friends/Social-Cultural - Socialize with others and make many friends
Background:
Religious Affiliations: - Muslim
Smoking/Drinking/Drugs: - Smoking 10 stick per day since 17 years old
- Denies any recent alcohol intake
- Denies any substance or drug
PREMORBID PERSONLITY:
(Preferably From Relatives
Or Friends)
Previous Medical History: - On ward medical at Hospital Kota Tinggi, Johor due
to MVA ( car vs motorcycle )
- Doesn’t remember any treatment given
- Multiple injuries including head
Previous Psychiatry History: - Had mental illness since he was 30 years old
- Multiple admission to Hospital Permai
- Get treatment at home under Community Psychiatry
Unit ( CPU )

GENERAL APPEARANCE
AND BEHAVIOUR:
General Impression: - Middle age malay man
- Wearing hospital attire
State of Consciousness: - Conscious
Physical Appearance: - Short black hair
- Asthenic body
Manner of - Can manage himself well
Dressing/Cleanliness: - Good hygiene
Facial Expression and - Patient happy and always in a good mood
Posture:
Reactivity to Surrounding: - Good eye contact
Mannerisms: - Good mannered
Ability to Co-operate: - Able to cooperate
TALK:
Languages/Dialect Spoken: - Bahasa Melayu
Amount of Talk: - Very talkative
Rational/Relevance/Coheren - Good
ce:
Flights of Ideas: - Had many idea
Looseness or Clang - Poor
Association:
Thought Block: - None
Circumstantiality: - None
Neologies (Quote Speech - None
Samples):
Pressure of Speech: - No pressured
Word Salad: - None
MOODS:
Mood State: - Showed his feeling well when talking
Affective Response: - Not elated affects
Consistency of Mood: - Good
Withdrawal: - None
THOUGHT CONTENTS:
Delusion & - None
Misinterpretations:
Feelings of Influence: - None
Feelings of Passivity: - None
Depersonalizations: - None
Hypochondrias:
Hallucinations: +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
Preoccupation: - None
Obsessions/Phobias: - Patient was obsess with knife, whenever he got the
knife he feel like he want to kill people
Over Determined Ideas: - None
Suicidal Thoughts: - Not suicidal
Repetitive Dreams: - None
(Described these in details)
ORIENTATION:
Place: - Patient is able answer and recognize where
Time: - Patient know what time is it
Person: - Patient can recognize people well

MEMORY:
Remote Memory: - Good
Recent Memory: - Good
Immediate Memory: - Good
Confabulation: - Good
Five Minutes Memory Test: - Patient can remember well
INFORMATION &
VOCABULARY:
Estimate Intelligence Level:
ABSTRACTION:
Proverbs Test:
ATTENTION &
CONCENTRATION:
Distractibility:
Serial Seven Test:
Digit Span:
JUDGEMENT:

INSIGHT:

PHYSICAL EXAMINATION:
GENERAL:
Temp: 36.4 C
Pulse Rate: 85
Resp. Rate: 20
B/P: 110/72 mm/hg
CARDIO-VASCULAR - Normal heart beat rate
SYSTEM: - 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 - Normal


SYSTEM: - 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. Perkara Wajaran Skor Catatan


1 Biodata pesakit 5
2 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)
3 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
4 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)
5 Ringkasan Penemuan Klinikal 5
6 Diagnosis:
6.1 Diagnosis Sementara 5
6.2 Diagnosis Perbezaan
7 Pengurusan:
7.1 Pengendalian awal
20
7.2 Ubat-ubatan
7.3 Penjagaan kejururawatan
8 Laporan reflektif 5
JUMLAH 100
Tandatangan Pemeriksa : ……………………………….……………

Nama : …………………………….………………

Tarikh : ……………………………………………

KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION

Nama Pelatih: ………………………………………… No. Matrik: ………….………...

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

PELAKSANAAN
Wajara Catata
Bil. Perkara Memua Lema Skor
n Baik n
skan h
Pembentangan biodata
1 pesakit yang tepat dan 1
lengkap

Pembentangan riwayat 2
2
pesakit yang lengkap
Melakukan penilaian
status mental yang 3
3
lengkap dan relevan
dengan tepat
Melakukan pemeriksaan
4 fizikal yang lengkap dan 1
relevan dengan betul
Cadangan diagnosis &
1
5 diagnosis perbezaan
yang tepat
Pembentangan
2
6 pengurusan pesakit yang
tepat dan lengkap
JUMLAH 10

Skor: …….........… x 100% = ..........................%


10

Tandatangan Pemeriksa : ……………………………….……………

Nama : …………………………….………………
Tarikh : ……………………………………………