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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

Religion: ISLAM

Sex: MALE

.

Age: …………. Race: MALAY

Marital Status: MARRIED

Occupation: RETIRED PENEROKA FELDA

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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: ………………………

Muhammad Kamal 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. precipitating factors. According to his daughter. Used Form 5 Malay - 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) List Complaints. duration. associate experience. . type of onset.REFERRAL SOURCE: (Referral forms attached) Language Spoken In History Taking: CHIEF COMPLAINTS: - Referred case from Emergency and Trauma Department Hospital Tuanku Jaafar Seremban. relieving factors.

000 Socialize with others and make many friends Muslim .Denies any substance or drug PREMORBID PERSONLITY: (Preferably From Relatives Or Friends) Previous Medical History: Previous Psychiatry History: none .000 married Patient has 7 children.Quit smoking many years ago .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: No problem None - Work as peneroka felda Peneroka Felda – RM3.Does not consume alcoholic . Stay with wife at Bukit Rokan RM3.

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: Feelings of Influence: Feelings of Passivity: Depersonalizations: Hypochondrias: Hallucinations: Preoccupation: Obsessions/Phobias: Over Determined Ideas: Suicidal Thoughts: Repetitive Dreams: (Described these in details) ORIENTATION: Place: Time: Person: .Malay man conscious - Can manage himself well Good hygiene Good eye contact Good mannered Able to cooperate Malay Average Relevant and coherent None None None None No pressured None Euthymic Good None Patient has persecutory delusion and denies any perceptional None None Not suicidal Patient is able answer and recognize where Patient know what time is it Patient can recognize people well .

patient claimed that his mathematic calculation is poor.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: Good Good Good Good Patient can remember well Unable to complete serial Seven test.No abnormal sound found during auscultation .Normal heart beat rate .4 C 85 20 110/72 mm/hg . No abnormal lung sound produce Breathe well ABDOMEN: - Normal No pain or organomegaly during palpation CENTRAL NERVOUS SYSTEM: .No murmur RESPIRATORY SYSTEM: - Chest expand normal. Digit Span: JUDGEMENT: INSIGHT: No insight PHYSICAL EXAMINATION: GENERAL: Temp: Pulse Rate: Resp. Rate: B/P: CARDIO-VASCULAR SYSTEM: 36.

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: ........... .....................................................................................................................................................

1 Diagnosis Sementara 6.3 Kepala & E/ENT 4.…………… Skor Catatan .5 Dada (Paru-paru) 4.9 Lain-lain (seperti genitalia & rektum.2 Diagnosis Perbezaan Pengurusan: 7.9 Judgement & Insight Pemeriksaan Fizikal: 4.7 Sistem Saraf 4.3 Mood 3.………………………… Bil.4 Dada (Jantung) 4.KURSUS DIPLOMA PEMBANTU PERUBATAN FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING Nama Pelatih: ………………………………………… No.8 Attention & Concentration 3.2 Ubat-ubatan 7. Tahun: …… Semester: ……… Kawasan Penempatan: .2 Sejarah Penyakit Kini 2..6 Abdomen 4.4 Sejarah Keluarga 2.7 Information.Vocabulary & Abstraction 3.5 Sejarah Personal (Lain2 yang berkenaan) Penilaian Staus Mental: 3.8 Anggota Atas & Bawah 4.2 Percakapan 3.……….2 Tanda-tanda Vital 4..1 Pengendalian awal 7. Matrik: ………….1 Pemeriksaan Am 4.6 Memori 3.4 Pemikiran 3.3 Penjagaan kejururawatan Laporan reflektif JUMLAH Tandatangan Pemeriksa Wajaran 5 25 25 10 5 5 20 5 100 : ……………………………….1 Aduan Utama 2. 1 2 3 4 5 6 7 8 Perkara Biodata pesakit Riwayat Pesakit: 2.3 Sejarah Dari Ahli Keluarga 2. dll) Ringkasan Penemuan Klinikal Diagnosis: 6.1 Keadaan Am & Tingkah Laku 3.5 Orientasi 3.

Matrik: …………...…………… Nama : ……………………………..........………………………… Bil..............% 10 Tandatangan Pemeriksa : ………………………………......… x 100% = . Perkara Wajaran 1 Pembentangan biodata pesakit yang tepat dan lengkap 2 Pembentangan riwayat pesakit yang lengkap 3 4 5 6 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 PELAKSANAAN Memuas Baik Lemah kan 1 2 3 1 1 2 10 Skor: ……... Tahun: …… Semester: ……… Kawasan Penempatan: ..………....……………… Tarikh : …………………………………………… Skor Catatan ..Nama : ……………………………..……………… Tarikh : …………………………………………… KURSUS DIPLOMA PEMBANTU PERUBATAN SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION Nama Pelatih: ………………………………………… No.