PSYCHIATRIC CLERKING SHEET

PSYCHIATRIC HISTORY
PRELIMINARY A 45 year old Chinese male
INFORMATION
Source of Referral Language spoken in Chinese
Accompanying Person Brought in by police officer for aggressive behavior
Language Spoken

CHIEF COMPLAINT A 45 y/o Chinese male thinks there are people a out there trying to kill him
He is aggressive towards his family members and has paranoid ideas.

HISTORY OF PRESENT He has aggressive behavior for the past one month. He also had auditory
hallucination and has delusions.
ILLNESS

From Patient/Accompanying Patient’s elder sister said he has been throwing glasses and carrying sharp
objects pointing to family members.
Person

When was he last well He thinks he is normal.

Nature of Complaint

Development over time Patient has been having more auditory hallucinations at night; He gets
aggressive and have paranoid ideas and attempted to throw things at home.
Precipitating / Relieving
factors
Help given so far and its
effect

Biological Functions Patient is unable to sleep well, has normal appetite and toilet habits.
Sleep, Appetite, Toilet Habits He likes reading Chinese books.
Sexual Function/
Concentration
Ability to enjoy

Stressor

Level of Function ADL independent

Social roles and Function
Activities of Daily Living
NAME: I/C:

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Social Supports None

NAME: I/C:

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PSYCHIATRIC HISTORY 3
PERSONAL HISTORY

BIRTH/INFANCY No history of childhood illness

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

SCHOOLING Studied up to SPM . Normal academic performance,

Highest Level Achieved No learning problems or problems with social interactions.
Academic Performance
Learning Problems
Social Interactions
Clubs/Games
Changes In School And
Reason
Non Attendance In School

WORK HISTORY
Age At Starting Work
List Of Jobs
Reason Of Change Of Jobs Start work at age 18 at local motorbike shop.
Periods Of Unemployment Unemployed since past 3 years
Job Satisfaction
Performance

RELATIONSHIPS
Friendships And Sexual
Contact
Marital Relationship And Not married. No children.
Difficulties
Children And Their Issues

SOCIO-ECONOMIC
STATUS
Family Income
Assets and Debts He is currently staying with his elder sister. Sister works as an accountant.
Stable income.
Facilities at Home
Environmental Concerns

NAME: I/C:

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PSYCHIATRIC HISTORY 4
HABITS Patient does not smoke, drink or do drugs. There is no religious practices,
gambling or visits to prostitutes.
Religious Practices
Smoking / Drinking / Drugs
Gambling / Visits to Prostitutes

NAME: I/C:

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PSYCHIATRIC HISTORY 5
FAMILY HISTORY

FAMILY CHART Elder sister age 50, accountant

Age and Marital Status Dad and mother passed away due to old age
Occupation and Residence No family conflict.
Family Relationships /
Conflict

FAMILIAL DISORDERS None

Mental Illness / Suicide
Substance Use / Epilepsy

PREMORBID N/A
PERSONALITY
From patient and informant
Introvert / Extrovert
Controlled / Impulsive
Stability of Mood / Actions
Assertiveness / Self Esteem
Sociability
Past Reaction to Stress

PAST HISTORY
Medical NKMI

Psychiatric None
Past Episodes
Response to Treatment
Past Deliberate Self-harm

Present Medication None

NAME: I/C:

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PSYCHIATRIC EXAMINATION
GENERAL APPEARANCE Chinese male in his 40s . He appears to be well groom and is cooperative
Grooming and social behavior
Rapport and ability to There is no signs of restlessness
cooperate
Restlessness and distractibility He does not get distracted.
Posture and motor activity Normal posture. There is no movement disorders, he is able to walk
properly.
Movement disorders There is no compulsive behavior noted. There is good eye contact and
hearing difficulty
Compulsive behavior
MOOD Mood is depressed, affect is congruent and reactive, There is no
anxiousness, irritability, no suicidal thought.
Depressed / Elated / Labile
Anxious / Irritable
Blunted / Restricted
Congruent / Incongruent
Suicidal Thought / Plans
THOUGHT / SPEECH

FLOW Normal speech, no thought block

Pressure / Poverty
Thought Block

FORM
Flight of Ideas Patient has paranoid ideas.
Looseness of Associations
Clang Associations / Punning
Circumstantiality / Relevance
Neologism
Quote speech if possible
POSSESSION OF There is no thought insertion or thought broadcasting
THOUGHT
Thought Insertion /
Withdrawal
Thought Broadcasting
CONTENT OF THOUGHT Patient has delusion of persecution, in which he thinks people are trying to
harm him.
Delusions
Describe in detail
Delusion of Control / Passivity
Delusion Mood / Memory
Delusion Perception
Obsession / Phobias
Over determined Ideas
Preoccupations
Body Image

PERCEPTUAL
DISTURBANCES
Hallucinations
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PSYCHIATRIC EXAMINATION
Describe in detail
Auditory / Visual / Somatic He felt that he is hearing voices people knocking the door trying to kill him
Smell / Taste
Illusions
Depersonalization .
Derealisation
Déjà vu / Jamais vu
NAME: I/C:

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PSYCHIATRIC EXAMINATION 2
COGNITIVE FUNCTION
MMSE SCORE

ORIENTATION He is oriented to time place and person

Time / Place / Person

MEMORY Immediate and remote memory was good.

Immediate / Recent / Remote
5 minute memory test
Confabulation

ATTENTION AND Could do digit span and serial 7.

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

ABSTRACTION He understands proverbs, similarities and differences

Proverbs
Similarities / Differences

JUDGEMENT Good judgment, no future plans.

Test situation
Future plans

INSIGHT Not aware of his signs and symptoms.

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 : 138/99, PR 70 RR 20 SPO 97% Temp 36

EXAMINATION
Vital signs
Height and weight
Waist circumference
Basal metabolic index

Significant Physical Findings

NAME: I/C:

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DIAGNOSIS Schizophrenia
Bipolar disorder
Axis I
Axis II
Axis III
Axis IV
Axis V

MANAGEMENT Refer medical , did ecg, , monitar vital sign

INVESTIGATION Normal

Full Blood Count

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

PSYCHO – SOCIAL
INTERVENTION

MEDICATION T Quetiapin IR 400MG BD

T Valium 5mg OM, 10mg ON

ADJUNCT THERAPHY

REHABILITATION

Doctors name and signature

Date

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NAME: I/C:

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