PSYCHIATRIC CLERKING SHEET

PSYCHIATRIC HISTORY
PRELIMINARY INFORMATION
Source of Referral
Accompanying Person
Language Spoken
A 30 year old Indian male
Language spoken in Malay and Tamil
Brought in by ambulance for due to deliberate self harm

CHIEF COMPLAINT A 30 year old Indian Male came in due to an episode of deliberate self harm- cuts
himself with a pocket knife at home.

HISTORY OF PRESENT He cuts anterior left wrist and right upper arm. This is his first episode of self
harm attempt. He also have been feeling depressed and low in energy for the past
2 months.
ILLNESS

From Patient/Accompanying Patient thought of killing himself for the past 2 days when he was alone at home.
He felt demotivated to live.
Person

When was he last well Patient could not remember when he was well.
Nature of Complaint

Development over time No accompany person was available to give history of development.
Precipitating / Relieving factors Stressors include thinking about his children and low salary.
Help given so far and its effect

Biological Functions Patient has insomnia, loss of appetite,fatigue for the past 2 months
Sleep, Appetite, Toilet Habits Normal toilet habits
Sexual Function/ Concentration Low concentration
Ability to enjoy

Stressor Thinking about his children and low salary income

Level of Function ADL independent

Social roles and Function
Activities of Daily Living

None

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Social Supports

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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 high school . Normal academic performance, but does not enjoy studying.
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 He works as a lorry driver at age 21, delivering goods around Tampin
List Of Jobs Due to pandemic his work load decrease and so was his income.
Reason Of Change Of Jobs
Periods Of Unemployment
Job Satisfaction
Performance

RELATIONSHIPS
Friendships And Sexual Contact Divorced for one year. 2 children.
Marital Relationship And
Difficulties
Children And Their Issues

SOCIO-ECONOMIC STATUS
Family Income Older brother working in KL.

Assets and Debts

Facilities at Home
Environmental Concerns

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

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PSYCHIATRIC HISTORY 5
FAMILY HISTORY

FAMILY CHART Elder brother age 40 manager

Age and Marital Status Dad 80, Mother 75.
Occupation and Residence No family conflict.
Family Relationships / Conflict

FAMILIAL DISORDERS None

Mental Illness / Suicide
Substance Use / Epilepsy

PREMORBID PERSONALITY Patient is an introvert

From patient and informant Stable mood
Introvert / Extrovert Controlled behavior
Controlled / Impulsive Fair self esteem
Stability of Mood / Actions Not sociable
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

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PSYCHIATRIC EXAMINATION
GENERAL APPEARANCE Indian male in his 30s in hospital attire. He appears to be well groom and is cooperative.
Grooming and social behavior Not restless
Rapport and ability to cooperate Good posture
Restlessness and distractibility Good motor activity
Posture and motor activity Not compulsive
Movement disorders
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 Thought and speech is normal

FLOW Normal speech, no thought block

Pressure / Poverty
Thought Block

FORM
Flight of Ideas No flight of ideas
Looseness of Associations
Clang Associations / Punning
Circumstantiality / Relevance
Neologism
Quote speech if possible
POSSESSION OF THOUGHT There is no thought insertion or thought broadcasting
Thought Insertion / Withdrawal
Thought Broadcasting
CONTENT OF THOUGHT Patient has no delusions
Delusions
Describe in detail
Delusion of Control / Passivity
Delusion Mood / Memory
Delusion Perception
Obsession / Phobias
Over determined Ideas
Preoccupations
Body Image

PERCEPTUAL DISTURBANCES
Hallucinations
Describe in detail
Auditory / Visual / Somatic No hallucinations
Smell / Taste
Illusions
Depersonalization .
Derealisation
Déjà vu / Jamais vu
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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 including days of the week
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 Has good insight of his illness

Awareness of signs / symptoms He thinks is due to missing his children too much
observed by others Stressed out from low salary income and beating himself up.
Does he think they are
abnormal
What does he think they are
due to
Does he think he needs
treatment / medication

PHYSICAL EXAMINATION BP : 120/95, PR 65 RR 15 SPO 97% Temp 36.5

Vital signs
Height and weight
Waist circumference
Basal metabolic index

Significant Physical Findings

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DIAGNOSIS MDD with alleged self harm

Axis I
Axis II
Axis III
Axis IV
Axis V

MANAGEMENT Monitor vital signs, ecg

INVESTIGATION Normal fbc, renal profile, fasting glucose and thyroid function

Full Blood Count

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

PSYCHO – SOCIAL CBT

INTERVENTION

MEDICATION 1. T sertraline 50mg OM

2. T Lorazepam 1mg PRN

ADJUNCT THERAPHY

REHABILITATION

Doctors name and signature

Date

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