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 Sex: MALE Age: …………. Race: MALAY Religion: ISLAM 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: ………
REFERRAL SOURCE: (Referral forms attached)
- Referred case from Emergency and Trauma Department Hospital Tuanku Jaafar
Seremban. - Used Form 5 Language Spoken In History
Taking:
- Malay
CHIEF COMPLAINTS: - 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)
According to his daughter, Muhammad Kamal
List Complaints, type of onset, duration, precipitating factors, relieving factors, associate experience.
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: No problem Neurotic Problems and
Health In Childhood: None School: -Academic Record: -Activities/Social Ability: Examination/Grades and Dates:
Work Record: Work as peneroka felda List Jobs/Salaries: Peneroka Felda – RM3,000 Reasons for Changes:
-Sexual Experience: Menstrual History:
Marriage(s): married Age, Occupation and
Personality of Spouse:
Sexual Practice/Children: Patient has 7 children. List Ages and Occupation:
-Miscarriages/Social-Cultural Background:
Present Home: Stay with wife at Bukit Rokan Total Family Income: RM3,000
Friends/Social-Cultural Background:
Socialize with others and make many friends Religious Affiliations: Muslim
Smoking/Drinking/Drugs: - Quit smoking many years ago - Does not consume alcoholic - Denies any substance or drug PREMORBID PERSONLITY:
(Preferably From Relatives Or Friends)
Previous Medical History:
GENERAL APPEARANCE AND BEHAVIOUR:
General Impression: - Malay man
-State of Consciousness: conscious Physical Appearance:
Manner of
Dressing/Cleanliness:
- Can manage himself well - Good hygiene
Facial Expression and Posture:
Reactivity to Surrounding: Good eye contact Mannerisms: Good mannered Ability to Co-operate: Able to cooperate TALK:
Languages/Dialect Spoken: Malay Amount of Talk: Average Rational/Relevance/Coheren
ce:
Relevant and coherent Flights of Ideas: None
Looseness or Clang Association:
Thought Block: None Circumstantiality: None Neologies (Quote Speech
Samples):
None
Pressure of Speech: No pressured
Word Salad: None
MOODS:
Mood State: Euthymic Affective Response:
Consistency of Mood: Good
Withdrawal: None
THOUGHT CONTENTS: Delusion &
Misinterpretations: Patient has persecutory delusion and denies any perceptional Feelings of Influence: Feelings of Passivity: Depersonalizations: Hypochondrias: Hallucinations: Preoccupation: Obsessions/Phobias: None Over Determined Ideas: None Suicidal Thoughts: Not suicidal Repetitive Dreams:
(Described these in details) ORIENTATION:
Place: Patient is able answer and recognize where Time: Patient know what time is it
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: Unable to complete serial Seven test, patient claimed that his mathematic calculation is poor.
Digit Span: JUDGEMENT: INSIGHT: No 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 rateNo 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:
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 Memuaskan Lemah
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 : ……….……… Tarikh : ………
