INSTITUSI LATIHAN KEMENTERIAN MALAYSIA

DIPLOMA PEMBANTU PERUBATAN

TAHUN 2 SEMESTER 2
MABS 2212
PSYCHIATRIC CASE CLERKING

Nama:MOHD. IMANNUDDIN BIN AZIMIN

No ic:000410-13-1581
No matrik:BPP2019-0334
Ambilan:JANUARI 2019
 KURSUS DIPLOMA PEMBANTU PERUBATAN

PSYCHIATRIC CASE CLERKING

Patient’s Biodata

Name: …EN.X……………………………… I/C No.:…………………..-……………….

Date of Birth: …5/6/1978….. Sex: .MALE…… Age: …………. Race: MELAYU…….

Religion: …ISLAM………………….. Marital Status: ……………………………...………

Occupation: …NOT WORKING……………………………………………………………

Present Address: Kampung Tambe Kota Samarahan……………………….……….

…………………………………………………………………………………….…………....

Telephone: (H) ………-…………………… (H/P) ……………-……..…………………

Name of Next of Kin: …………EN.Y…………….. I/C No.: ……-……..…………………

Relationship:…….Father………………………. Occupation: …………-….……………

Address:Kampung Kota Sentosa………………………………………………….…

………………………………………………………………………………………………….

Telephone: (H) ……………………………… (H/P) ………………………………………

Admission Status: Voluntary

Temporary Nyatakan Borang Akta KesihatannMental 2001

Compulsory
3DAN 4
Number of previous admission (If any): ………1…………………………………………

Registration Number (If any): ………………109424………………………………………

ADMISSION: DISCHARGE:

Date: ……………………………. Date: ………………………

Time: …………………………… Time: ………………………

REFERRAL SOURCE:
(Referral forms attached)
Language Spoken In History
Taking:
CHIEF COMPLAINTS:
HISTORY OF PRESENT
ILLNESS:
HISTORY FROM
RELATIVES:
(State relationship and name
of informant)
List Complaints, type of
onset, duration, precipitating
factors, relieving factors,
associate experience.
ABILITY FOR WORK:
SLEEP PATTERN:
APPETITE:
TOLET HABITS:
Walk in
Bahasa Melayu
Disorganized behaviour x3/7
-feeling unwell since this past 2/12
-can hear voice and see figures of “makhluk halus”
-mixed voice
=commanding
=second person
=asking him to go here and there
=sometime cursing and scolding him
-see them as human figure (man and woman)
-fell scared
-persection decession
-claim that his relative use black magic on him
-no delusion ,no suicidal thoughts
-poor sleep (due to the disturbance)
-no fever
-admit to stiffing glue
=small tin sometime
=spent about RM 3 each time
=duration >10 years
-deny taking other substance
Father
-noticed patient unwell x3/12
-out wandering come home late (past midnight)
-self talking on and off
-no aggressive behaviour
-poor oral intake
-Went to granmother’s house, sleep outside shaking
fence/door
-disorganised speech
-Poor sleep due to the disturbance
-Poor oral intake
-dont have any problem in tolet habit
TREATMENT FROM
WHATEVER SOURCES:
Types of Treatment Given:
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:
Friends/Social-Cultural
Background:
Religious Affiliations:
Smoking/Drinking/Drugs:
-
-his father divorce with his mother and remarried
-have 3 younger siblings
-first sibling: 22 years old and still study
-second sibling: 19 years old and still study
-third sibling: 18 years old and still study
-no history about his family having psychiatry ilness
Born via SUD
No significant ilness
No significant ilness
Study until primary 6
Dropped because patient did not intrested
-
-
-Work for geoscope company (kaji bumi)
-Work for 10 years and stopped 3 years ago because
he wanted to help his father. (farming and fishing)
-Geoscope company
-farming and fishing= rm30-rm50(from his father)
-want to help his father
-
-
single
-
-
-
Kampung Tambe Kota Samarahan
-
-
-smoking half pack /day

PREMORBID
PERSONLITY: (Preferably
From Relatives Or Friends)
Previous Medical History:
-drinks beer somtimes
-gule=3-4 tin each time
Quite and friendly
-

Previous Psychiatry History: -

GENERAL APPEARANCE
AND BEHAVIOUR:
General Impression: Neat

State of Consciousness: Alert, conscious

Physical Appearance: Medium built
Manner of Neat, casual attire
Dressing/Cleanliness:
Facial Expression and Calm
Posture:
Reactivity to Surrounding: Eye contact poor
Mannerisms: No abnormal movement
Ability to Co-operate: Cooperative
TALK:
Languages/Dialect Spoken: Malay
Amount of Talk: Moderate
Rational/Relevance/ Correct, relevant
Coherence:
Flights of Ideas: -
Looseness or Clang -
Association:
Thought Block: -
Circumstantiality: -
Neologies (Quote Speech -
Samples):
Pressure of Speech: -
Word Salad: -
MOODS:
Mood State:
Affective Response: reactive
Consistency of Mood: consistent
Withdrawal: -
THOUGHT CONTENTS:
Delusion & -
Misinterpretations:
Feelings of Influence: -
Feelings of Passivity: -
Depersonalizations: -
Hypochondrias: -
Hallucinations: Aiditory hallucination (female voice, voice telling him
 to gargle)
Preoccupation: -
Obsessions/Phobias: -
Over Determined Ideas: -
Suicidal Thoughts: -
Repetitive Dreams: -
(Described these in details)
ORIENTATION:
Place: -can tell where he is ‘hospital’
Time: -unable to tell exect date , but know about year
Person: -can tell about person who you ask ‘doktor’

MEMORY:
Remote Memory: -can tell about his child memory such as his previous
school
Recent Memory: -remember about who brougth him to hospital
Immediate Memory: -can tell what he eat during lunch
Confabulation: -
Five Minutes Memory Test: -Interact
=bola,kayu,kereta
INFORMATION &
VOCABULARY:
Estimate Intelligence Level: -Average
ABSTRACTION:
Proverbs Test: -Kaki bangku
=tidak dapat main bola
ATTENTION &
CONCENTRATION:
Distractibility:
Serial Seven Test: 100-7=93-7=86-7=71
Digit Span:
JUDGEMENT: -Normal
=’kalau nampak rumah terbakar-panggil bomba’
INSIGHT: -pt have a very good insight
-pt know what to do on his own
PHYSICAL EXAMINATION: normal
GENERAL: Well-develope,oriented to time,place,person and
alert to situation
Temp: 36.8
Pulse Rate: 70
Resp. Rate: 20
B/P: 105/67
CARDIO-VASCULAR I-No scar
SYSTEM: P-Dullness sound
P-No tenderness
A-No extra sound, no mumur

RESPIRATORY SYSTEM: I-respiratory excursions full and assymetrical

P-resonant sound
P-no tendderness
 A-clear sound(no rales, ronchi, wheezing or rubs)

ABDOMEN: I- Scaphoid without scar

P- No abnormal tympany
Q- Soft and no tenderness
A- Normal bowel sound

CENTRAL NERVOUS
SYSTEM:

SUMMARY OF PHYSICAL FINDINGS:

-no jaundice
-no swelling -clear air
-no pallor entry
-no ronchi
-no cyanosis -no crepitus
-no clubbing
fingers

-dual -Soft
rhythm -no tenderness
-no
murmur

-no piting edema

List chief clinical features below:

Pt physically normal,no scar, no tenderness and abnormalities. He just have auditory
and visual hallucination if he skip his medication.

DIAGNOSIS: -Substance induce psychosis

DIFFERENTIAL
DIAGNOSIS: -Schizophrenia disoder
TREATMENT PLAN: 1. T. Risperidone 1mg ON 1/52
T. clonazepam 0.5mg ON/PRN
2. Advise abstinence from substance
3. Psycho education
4. TCA stat if unwell
5. For FBC/BUSE/UN/LFT/TFT
6. Urine test

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:

It was my second time attach at Hospital sentosa. It is fun and I learn alot
here. I need to attach at Hospital sentosa for 4 week . there is alot of new things that
I learnt such as MSE , how to withdraw blood from PT and ECT.
I make alot of progres here because I spend most of my sem 3 at home.
Thank to the staff there because they will freely answer our question. I feel
disapointed because the first day during the attachment is boring because it hard to
learnt at hospital Sentosa. I started to enjoy there because I can learn alot of new
things there.