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:
- Malay
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
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)
- According to his father, Encik Ibrahim bin Haji Samat
List Complaints, type of onset, duration, precipitating factors, relieving factors, associate experience.
- 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. 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
WHATEVER SOURCES:
- Was admit in Hospital Kota Tinggi due to MVA ( Car vs Motorcycle ) since 8 years ago
FAMILY HISTORY: Father/Mother:
Siblings/Other Relatives:
Ages and Occupation:
Emotional Relationship: - Is good with family members Economic Status/Social
Standing: - Good economic, family was in middle class stage- Good social, all family members can socialize with others
Mental Illness or Other
Diseases In Family: - Mother and his young brother has mental illness and never get treatment PERSONAL HISTORY:
Birth/Milestone: - SVD and no problem during delivered Childhood: - No problems
Neurotic Problems and Health In Childhood:
- None
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
Dates:
- Failed in SRP in year 1986
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
Personality of Spouse: - 42 years old, work as guard Sexual Practice/Children: - None
List Ages and Occupation: - None Miscarriages/Social-Cultural
Background: - None
Present Home: - Staying at home with his father and mother in Kota Tinggi, Johor Baharu
Friends/Social-Cultural Background:
- Socialize with others and make many friends 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
Dressing/Cleanliness:
- Can manage himself well - Good hygiene
Facial Expression and Posture:
- Patient happy and always in a good mood 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
ce:
- Good
Flights of Ideas: - Had many idea Looseness or Clang
Association: - Poor Thought Block: - None Circumstantiality: - None Neologies (Quote Speech
Samples):
- None
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 &
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:
(Described these in details)
- None 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 SYSTEM:
- 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:
DIAGNOSIS: DIFFERENTIAL DIAGNOSIS:
- Schizophrenia
TREATMENT PLAN: Admit to blossom C Tab Vallium 10 mg prn 1 to 1 nursing care
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 2.4 Sejarah Keluarga
2.5 Sejarah Personal (Lain2 yang berkenaan)
25
3 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
25
4 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)
10
5 Ringkasan Penemuan Klinikal 5 6 Diagnosis: 6.1 Diagnosis Sementara 6.2 Diagnosis Perbezaan 5 7 Pengurusan: 7.1 Pengendalian awal 7.2 Ubat-ubatan 7.3 Penjagaan kejururawatan 20 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: ...………
Bil. Perkara Wajaran
PELAKSANAAN Skor Catatan Baik Memua skan Lema h
1 Pembentangan biodata pesakit yang tepat dan lengkap
1
2 Pembentangan riwayat pesakit yang lengkap 2
3
Melakukan penilaian status mental yang lengkap dan relevan dengan tepat
3
4
Melakukan pemeriksaan fizikal yang lengkap dan relevan dengan betul
1
5
Cadangan diagnosis & diagnosis perbezaan yang tepat
1
6
Pembentangan
pengurusan pesakit yang tepat dan lengkap
2 JUMLAH 10 Skor: ……...… x 100% = ...% 10 Tandatangan Pemeriksa : ……….……… Nama : ……….………