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: ………………………

Time: …………………………… Time: ………………………

REFERRAL SOURCE: - Referred case from Emergency and Trauma
(Referral forms attached) Department Hospital Tuanku Jaafar
Seremban.
- Used Form 5
Language Spoken In History - Malay
Taking:
CHIEF COMPLAINTS: - Abnormal behavior x 1 year
- Aggressive behavior x 3/7

HISTORY OF PRESENT No known present illness

ILLNESS:

HISTORY FROM According to his daughter, Muhammad Kamal

RELATIVES:
(State relationship and name
of informant)
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 Private psychiatrist from Hospital Colombia Asia

WHATEVER SOURCES:

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 None
Health In Childhood:
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 Socialize with others and make many friends
Background:
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:

Previous Psychiatry History: none

GENERAL APPEARANCE
AND BEHAVIOUR:
General Impression: - Malay man
-
State of Consciousness: conscious
Physical Appearance:
Manner of - Can manage himself well
Dressing/Cleanliness: - 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 Relevant and coherent
ce:
Flights of Ideas: None
Looseness or Clang
Association:
Thought Block: None
Circumstantiality: None
Neologies (Quote Speech None
Samples):
Pressure of Speech: No pressured
Word Salad: None
MOODS:
Mood State: Euthymic
Affective Response:
Consistency of Mood: Good
Withdrawal: None
THOUGHT CONTENTS:
Delusion & Patient has persecutory delusion and denies any
Misinterpretations: 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
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: 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 - 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
SYSTEM:
SUMMARY OF PHYSICAL FINDINGS:

List chief clinical features below:

DIAGNOSIS:

DIFFERENTIAL
DIAGNOSIS:

TREATMENT PLAN:
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 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
Bil. Perkara Wajaran Memuas Skor Catatan
Baik Lemah
kan

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 : ……………………………………………