REFERRAL SOURCE: (Referral forms attached) Language Spoken In History Taking: CHIEF COMPLAINTS:

- Referred case from Hospital Kota Tinggi Johor - Used form 3 and 4 with police referral letter ( Pol 57) - Malay - Aggressive behavior with psychotic symptoms since 1/12 ago - Have auditory hallucination and visual hallucination - Become worst since 1/52 before pre admission - 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 didnt compliance to medication - Had on off taking medicine - Patient claim always forget to take medicine and unsure either he compliance to injection or not. - According to his father, Encik Ibrahim bin Haji Samat - 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. - Patient is able to work and obey to command - Patient admit he has poor sleep and only can sleep 5 hour per day - Patient has good appetite - BO and PU had no problem - Was admit in Hospital Kota Tinggi due to MVA ( Car vs Motorcycle ) since 8 years ago - Toilet & Suture and nursing care

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: 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:

- Is good with family members - Good economic, family was in middle class stage - Good social, all family members can socialize with others - Mother and his young brother has mental illness and never get treatment - SVD and no problem during delivered - No problems - None - Sek. Keb. Bandar Mas, Kota Tinggi - Sek. Men. Keb. Air Tawar , Kota Tinggi - Sijil Rendah Pelajaran ( Form 3 ) - Talkative and have many friends - Failed in SRP in year 1986 - 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 - Worked in factory in year 1990 : ( RM 300 ) - Worked as a guard in year 2011 : ( RM 900 ) - Not suitable for him - His illness becomes worst because not compliance medication - None - Puberty at 12 years old, - Non-married - 42 years old, work as guard - None - None - None - Staying at home with his father and mother in Kota Tinggi, Johor Baharu - RM 3000

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: PREMORBID PERSONLITY: (Preferably From Relatives Or Friends) Previous Medical History:

- Socialize with others and make many friends - Muslim - Smoking 10 stick per day since 17 years old - Denies any recent alcohol intake - Denies any substance or drug

Previous Psychiatry History:

- On ward medical at Hospital Kota Tinggi, Johor due to MVA ( car vs motorcycle ) - Doesnt remember any treatment given - Multiple injuries including head - 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: State of Consciousness: Physical Appearance: Manner of Dressing/Cleanliness: Facial Expression and Posture: Reactivity to Surrounding: Mannerisms: Ability to Co-operate: TALK: Languages/Dialect Spoken: Amount of Talk: Rational/Relevance/Coheren ce: Flights of Ideas: Looseness or Clang Association: Thought Block: Circumstantiality: Neologies (Quote Speech Samples): Pressure of Speech: Word Salad: MOODS: Mood State: Affective Response: Consistency of Mood: Withdrawal: THOUGHT CONTENTS: Delusion & Misinterpretations:

- Middle age malay man - Wearing hospital attire - Conscious - Short black hair - Asthenic body - Can manage himself well - Good hygiene - Patient happy and always in a good mood - Good eye contact - Good mannered - Able to cooperate - Bahasa Melayu - Very talkative - Good - Had many idea - Poor - None - None - None - No pressured - None - Showed his feeling well when talking - Not elated affects - Good - None - None

Feelings of Influence: Feelings of Passivity: Depersonalizations: Hypochondrias: Hallucinations:

- None - None - None +AH : - Heard mans 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 - None - Patient was obsess with knife, whenever he got the knife he feel like he want to kill people - None - Not suicidal - None - Patient is able answer and recognize where - Patient know what time is it - Patient can recognize people well

Preoccupation: Obsessions/Phobias: Over Determined Ideas: Suicidal Thoughts: Repetitive Dreams: (Described these in details) ORIENTATION: Place: Time: Person:

MEMORY: Remote Memory: Recent Memory: Immediate Memory: Confabulation: Five Minutes Memory Test: INFORMATION & VOCABULARY: Estimate Intelligence Level: ABSTRACTION: Proverbs Test: ATTENTION & CONCENTRATION: Distractibility: Serial Seven Test: Digit Span: JUDGEMENT: INSIGHT: PHYSICAL EXAMINATION: GENERAL:

- Good - Good - Good - Good - Patient can remember well

Temp: Pulse Rate: Resp. Rate: B/P: CARDIO-VASCULAR SYSTEM:

36.4 C 85 20 110/72 mm/hg - 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: TREATMENT PLAN:

- Schizophrenia

Admit to blossom C Tab Vallium 10 mg prn 1 to 1 nursing care I/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: ................................................................................................................................. ....................................................................................................................................... ....................................................................................................................................... ...................................................................................................................................... ....................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................

KURSUS DIPLOMA PEMBANTU PERUBATAN FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING Nama Pelatih: No. Matrik: ..

Tahun: Semester: Kawasan Penempatan: ... Bil. 1 2 Perkara Wajaran Biodata pesakit 5 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) 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 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) Ringkasan Penemuan Klinikal 5 Diagnosis: 6.1 Diagnosis Sementara 5 6.2 Diagnosis Perbezaan Pengurusan: 7.1 Pengendalian awal 20 7.2 Ubat-ubatan 7.3 Penjagaan kejururawatan Laporan reflektif 5 JUMLAH 100 Skor Catatan

5 6 7

Tandatangan Pemeriksa Nama Tarikh

: . : . :

KURSUS DIPLOMA PEMBANTU PERUBATAN SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION Nama Pelatih: No. Matrik: ....

Tahun: Semester: Kawasan Penempatan: ... Bil. Perkara Pembentangan biodata pesakit yang tepat dan lengkap Pembentangan riwayat pesakit yang lengkap Melakukan penilaian status mental yang lengkap dan relevan dengan tepat Melakukan pemeriksaan fizikal yang lengkap dan relevan dengan betul Cadangan diagnosis & diagnosis perbezaan yang tepat Pembentangan pengurusan pesakit yang tepat dan lengkap JUMLAH Wajara n 1 2 PELAKSANAAN Memua Lema Baik skan h Skor Catata n

1 1

2 10

Skor: ......... x 100% = ..........................% 10 Tandatangan Pemeriksa Nama : . : .

Tarikh