PSYCHIATRIC CLERKING SHEET

PSYCHIATRIC HISTORY
PRELIMINARY 50year old Malay male
INFORMATION
Source of Referral Brought in to ED by police
Accompanying Person Speaks in Malay
Language Spoken

CHIEF COMPLAINT Aggressive behavior , reduced sleep for one month

HISTORY OF PRESENT He is a known case of schizophrenia for one year and he is not compliant to
his medications for the past 6 months
ILLNESS

From Patient/Accompanying According to his 20 year old son, he has been aggressive and trying to harm
the neighbor , talks to himself and barely sleeps at night. He is easily
irritated when son questions him
Person

When was he last well Prior 6 months

Nature of Complaint

Development over time Ever since he stopped taking medications he has been getting more
aggressive at night towards his family members and neighbours.
Precipitating / Relieving
factors
Help given so far and its
effect

Biological Functions Barely sleeps at night, normal appetite and toilet habits.
Sleep, Appetite, Toilet Habits
Sexual Function/
Concentration
Ability to enjoy

Stressor Unable to identify

Level of Function ADL independent

Social roles and Function
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Activities of Daily Living

Social Supports

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PSYCHIATRIC HISTORY 2
PERSONAL HISTORY

BIRTH/INFANCY No childhood illness.

CHILDHOOD
Perinatal history
Childhood illness
Milestones
Childhood neurotic problems
Bedwetting/Tics

SCHOOLING Studied up till diploma, was a normal student. No learning problems, no

troubles with socialising
Highest Level Achieved
Academic Performance
Learning Problems
Social Interactions
Clubs/Games
Changes In School And
Reason
Non Attendance In School

WORK HISTORY Started working at age 25

Age At Starting Work Works as a clerk
List Of Jobs Have not been attending work due to his aggressive behaviour
Reason Of Change Of Jobs
Periods Of Unemployment
Job Satisfaction
Performance

RELATIONSHIPS Married. One son.

Friendships And Sexual
Contact
Marital Relationship And
Difficulties
Children And Their Issues

SOCIO-ECONOMIC Stable family income. Basic facilities at home

STATUS
Family Income
Assets and Debts
Facilities at Home
Environmental Concerns

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HABITS Is a muslim, does not smoke, drink , do drugs or gamble
Religious Practices
Smoking / Drinking / Drugs
Gambling / Visits to
Prostitutes

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PSYCHIATRIC HISTORY 3
FAMILY HISTORY

FAMILY CHART Father is 80 years old and Mother is 76 years old. Sister is 49 years old.
Age and Marital Status .
Occupation and Residence
Family Relationships /
Conflict

FAMILIAL DISORDERS No history of mental illness, substance abuse

Mental Illness / Suicide
Substance Use / Epilepsy

PREMORBID According to sister, he was a kind and loving brother. He’s an introvert and
PERSONALITY has stable
From patient and informant Mood. Normal self esteem and able to tolerate stress.
Introvert / Extrovert
Controlled / Impulsive
Stability of Mood / Actions
Assertiveness / Self Esteem
Sociability
Past Reaction to Stress

PAST HISTORY NKMI

Medical

Psychiatric Known case of schizophrenia for past one year. Admitted to the ward
Past Episodes
Response to Treatment
Past Deliberate Self-harm

Present Medication T Olanzapine 10mg BD

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PSYCHIATRIC EXAMINATION
GENERAL APPEARANCE Not well grommed
Grooming and social behavior Able to coorperate
Rapport and ability to Slight restless
cooperate
Restlessness and distractibility No compulsive behaviour
Posture and motor activity
Movement disorders
Compulsive behavior
MOOD Irritable mood, congruent affect, no suicidal thoughts
Depressed / Elated / Labile
Anxious / Irritable
Blunted / Restricted
Congruent / Incongruent
Suicidal Thought / Plans
THOUGHT / SPEECH

FLOW Speech is coherent, relevant and with normal tone, amount and rate
Pressure / Poverty
Thought Block

FORM No flight of ideas

Flight of Ideas
Looseness of Associations
Clang Associations / Punning
Circumstantiality / Relevance
Neologism
Quote speech if possible
POSSESSION OF No thought insertion or broadcasting
THOUGHT
Thought Insertion /
Withdrawal
Thought Broadcasting
CONTENT OF THOUGHT
Delusions
Describe in detail
Delusion of Control / Passivity He has delusions of his neighbours trying to team up to end his life
Delusion Mood / Memory
Delusion Perception
Obsession / Phobias
Over determined Ideas
Preoccupations
Body Image

PERCEPTUAL
DISTURBANCES
Hallucinations He has auditory hallucinations- loud banging on the door as if someone is
gonna bash in and throw him out.
Describe in detail
Auditory / Visual / Somatic
Smell / Taste
Illusions
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Depersonalization
Derealisation
Déjà vu / Jamais vu
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PSYCHIATRIC EXAMINATION 2
COGNITIVE FUNCTION
MMSE SCORE

ORIENTATION Oriented to time place and person

Time / Place / Person

MEMORY N/A
Immediate / Recent / Remote
5 minute memory test
Confabulation

ATTENTION AND N/A

CONCENTRATION
Digit span / Serial 7
Days of the week / month

ABSTRACTION N/A
Proverbs
Similarities / Differences

JUDGEMENT No future plans

Test situation
Future plans

INSIGHT No aware of his illness; Thinks he is normal

Awareness of signs /
symptoms
observed by others
Does he think they are
abnormal
What does he think they are
due to
Does he think he needs
treatment / medication

PHYSICAL BP 110/76, Pulse rate 86/min, RR: 16

EXAMINATION
Vital signs
Height and weight
Waist circumference
Basal metabolic index

Significant Physical Findings

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DIAGNOSIS Relapse schizophrenia due to noncompliance to medication

Axis I
Axis II
Axis III
Axis IV
Axis V

MANAGEMENT Pharmacotherapy

INVESTIGATION Full blood count , RP , LFT, TFT are normal

Full Blood Count

Renal / Liver / Thyroid
Function
Fasting Glucose / Lipid Profile
Others

PSYCHO – SOCIAL none

INTERVENTION

MEDICATION T Olanzapine 10mg BD

IV Valium 5mg PRN

ADJUNCT THERAPHY

REHABILITATION

Doctors name and signature

Date

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NAME: I/C:

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