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

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 membersEconomic 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 deliveredChildhood: - No problemsNeurotic 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 friendsExamination/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: - NoneMenstrual History: - Puberty at 12 years old, Marriage(s): - Non-marriedAge, 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

Total Family Income: - RM 3000

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 attireState of Consciousness: - Conscious Physical Appearance: - Short black hair

- Asthenic bodyManner 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 contactMannerisms: - Good manneredAbility to Co-operate: - Able to cooperateTALK:Languages/Dialect Spoken: - Bahasa MelayuAmount of Talk: - Very talkativeRational/Relevance/Coherence:

- Good

Flights of Ideas: - Had many ideaLooseness or Clang Association:

- Poor

Thought Block: - None Circumstantiality: - None Neologies (Quote Speech Samples):

- None

Pressure of Speech: - No pressuredWord Salad: - None MOODS:Mood State: - Showed his feeling well when talkingAffective Response: - Not elated affectsConsistency of Mood: - Good Withdrawal: - None THOUGHT CONTENTS:Delusion & Misinterpretations:

- None

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 himusually 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: - NoneSuicidal Thoughts: - Not suicidalRepetitive Dreams: (Described these in details)

- None

ORIENTATION:Place: - Patient is able answer and recognize whereTime: - Patient know what time is itPerson: - 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 CPulse Rate: 85Resp. Rate: 20B/P: 110/72 mm/hgCARDIO-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:

List chief clinical features below:

DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

- Schizophrenia

TREATMENT PLAN: Admit to blossom CTab Vallium 10 mg prn1 to 1 nursing careI/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:

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KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING

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

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

Bil. Perkara Wajaran Skor Catatan1 Biodata pesakit 52 Riwayat Pesakit:

2.1Aduan Utama2.2Sejarah Penyakit Kini2.3Sejarah Dari Ahli Keluarga2.4Sejarah Keluarga2.5Sejarah Personal(Lain2 yang berkenaan)

25

3 Penilaian Staus Mental:3.1Keadaan Am & Tingkah Laku3.2Percakapan3.3Mood3.4Pemikiran3.5Orientasi3.6Memori3.7 Information,Vocabulary & Abstraction3.8Attention & Concentration3.9Judgement & Insight

25

4 Pemeriksaan Fizikal:4.1Pemeriksaan Am4.2Tanda-tanda Vital4.3Kepala & E/ENT4.4Dada (Jantung)4.5Dada (Paru-paru)4.6Abdomen4.7Sistem Saraf4.8Anggota Atas & Bawah4.9Lain-lain (seperti genitalia & rektum, dll)

10

5 Ringkasan Penemuan Klinikal 56 Diagnosis:

6.1 Diagnosis Sementara6.2 Diagnosis Perbezaan

5

7 Pengurusan:7.1 Pengendalian awal7.2 Ubat-ubatan7.3 Penjagaan kejururawatan

20

8 Laporan reflektif 5JUMLAH 100

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

Nama : …………………………….………………

Tarikh : ……………………………………………

KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION

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

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

Bil. PerkaraWajara

n

PELAKSANAANSkor

CatatanBaik

Memuaskan

Lemah

1Pembentangan biodata pesakit yang tepat dan lengkap

1

2Pembentangan riwayat pesakit yang lengkap

2

3

Melakukan penilaian status mental yang lengkap dan relevan dengan tepat

3

4Melakukan pemeriksaan fizikal yang lengkap dan relevan dengan betul

1

5Cadangan diagnosis & diagnosis perbezaan yang tepat

1

6Pembentangan pengurusan pesakit yang tepat dan lengkap

2

JUMLAH 10

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

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

Nama : …………………………….………………

Tarikh : ……………………………………………