en. h psy

8/11/2019 En. H Psy

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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 Se: MA!" A#e: $$$$. %a&e: MA!A'

%e(i#io): IS!AM Marita( Stat*+: MA%%I"D

,&&*-atio): %"I%"D "N"%,A "!DA .

re+e)t A22re++: N, 41 "%INA 4 "!DA BUI %,AN "M"NCH"H

e(e-ho)e: H6 $$$$$$$$$$$$ H/6 $$$$$$$$..$$$$$$$

Name of Net of i): $$$$$$$$$$$$.. I/C No.: $$$$..$$$$$$$

%e(atio)+hi-: $$$$$$$$$$$$$$$. ,&&*-atio): $$$$$.$$$$$

A22re++: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.$

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.

e(e-ho)e: H6 $$$$$$$$$$$$ H/6 $$$$$$$$$$$$$$$

A2mi++io) Stat*+: 7o(*)tar8

em-orar8

Com-*(+or8

N*mer of -reio*+ a2mi++io) If a)86: $$$$$$$$$$$$$$$$$$$$

%e#i+tratio) N*mer If a)86: $$$$$$$$$$$$$$$$$$$$$$$$

ADMISSION: DISCHARGE:

Date: $$$$$$$$$$$. Date: $$$$$$$$$

ime: $$$$$$$$$$$ ime: $$$$$$$$$

8/11/2019 En. H Psy


REFERRAL SOURCE: %eferra( form+ atta&he26

; %eferre2 &a+e from "mer#e)&8 a)2 ra*maDe-artme)t Ho+-ita( *a)<* JaafarSerema).

; U+e2 orm 5

!a)#*a#e S-o<e) I) Hi+tor8a<i)#:

; Ma(a8

CHIEF COMPLAINTS: ; A)orma( ehaior 1 8ear ; A##re++ie ehaior 3/=

HISTORY OF PRESENTILLNESS:

No <)o>) -re+e)t i(()e++

HISTORY FROMRELATIES: State re(atio)+hi- a)2 )ameof i)forma)t6

A&&or2i)# to hi+ 2a*#hter M*hamma2 ama(

!i+t Com-(ai)t+ t8-e ofo)+et 2*ratio) -re&i-itati)#fa&tor+ re(iei)# fa&tor+a++o&iate e-erie)&e.

ABILITY FOR !ORK: atie)t i+ a(e to >or< a)2 oe8 to &omma)2

SLEEP PATTERN: U)a(e to +(ee- >e(( at )i#ht

APPETITE: %e2*&e2 a--etite

TOLET HABITS: B, a)2 U ha2 )o -ro(em

TREATMENT FROM!HATEER SOURCES: riate -+8&hiatri+t from Ho+-ita( Co(omia A+ia

8-e+ of reatme)t ie): ,ra( me2i&atio) *t -atie)t ref*+e2 the me2i&atio)from ho+-ita(.

8/11/2019 En. H Psy


FAMILY HISTORY:

ather/Mother:

Si(i)#+/,ther %e(atie+:

A#e+ a)2 ,&&*-atio):

"motio)a( %e(atio)+hi-:

"&o)omi& Stat*+/So&ia(

Sta)2i)#:

Me)ta( I(()e++ or ,therDi+ea+e+ I) ami(8:

PERSONAL HISTORY:

Birth/Mi(e+to)e:

Chi(2hoo2: No -ro(em

Ne*roti& ro(em+ a)2

Hea(th I) Chi(2hoo2:

No)e

S&hoo(: ;

A&a2emi& %e&or2: ;

A&tiitie+/So&ia( Ai(it8:

"ami)atio)/ra2e+ a)2Date+:

?or< %e&or2: ?or< a+ -e)ero<a fe(2a

!i+t Jo+/Sa(arie+: e)ero<a e(2a – %M3000

%ea+o)+ for Cha)#e+: ;

Se*a( "-erie)&e:

Me)+tr*a( Hi+tor8:Marria#e+6: marrie2

A#e ,&&*-atio) a)2er+o)a(it8 of S-o*+e:

Se*a( ra&ti&e/Chi(2re): atie)t ha+ = &hi(2re).

!i+t A#e+ a)2 ,&&*-atio): ;

Mi+&arria#e+/So&ia(;C*(t*ra(Ba&<#ro*)2:

re+e)t Home: Sta8 >ith >ife at B*<it %o<a)

ota( ami(8 I)&ome: %M3000

rie)2+/So&ia(;C*(t*ra(Ba&<#ro*)2:

So&ia(i@e >ith other+ a)2 ma<e ma)8 frie)2+

%e(i#io*+ Affi(iatio)+: M*+(im

Smo<i)#/Dri)<i)#/Dr*#+: ; *it +mo<i)# ma)8 8ear+ a#o; Doe+ )ot &o)+*me a(&oho(i&; De)ie+ a)8 +*+ta)&e or 2r*#

PREMORBID PERSONLITY:"P#e$e#a%&' F#o( Re&ati)esO# F#iends*

reio*+ Me2i&a( Hi+tor8:

reio*+ +8&hiatr8 Hi+tor8: )o)e

8/11/2019 En. H Psy


GENERAL APPEARANCEAND BEHAIOUR:

e)era( Im-re++io): ; Ma(a8 ma);

State of Co)+&io*+)e++: &o)+&io*+h8+i&a( A--eara)&e:

Ma))er ofDre++i)#/C(ea)(i)e++:

; Ca) ma)a#e him+e(f >e((; oo2 h8#ie)e

a&ia( "-re++io) a)2o+t*re:

%ea&tiit8 to S*rro*)2i)#: oo2 e8e &o)ta&t

Ma))eri+m+: oo2 ma))ere2

Ai(it8 to Co;o-erate: A(e to &oo-erate

TALK:

!a)#*a#e+/Dia(e&t S-o<e): Ma(a8

Amo*)t of a(<: Aera#e%atio)a(/%e(ea)&e/Cohere)&e:

%e(ea)t a)2 &ohere)t

(i#ht+ of I2ea+: No)e

!oo+e)e++ or C(a)# A++o&iatio):

ho*#ht B(o&<: No)e

Cir&*m+ta)tia(it8: No)e

Neo(o#ie+ *ote S-ee&hSam-(e+6:

No)e

re++*re of S-ee&h: No -re++*re2?or2 Sa(a2: No)e

MOODS:

Moo2 State: "*th8mi&

Affe&tie %e+-o)+e:

Co)+i+te)&8 of Moo2: oo2

?ith2ra>a(: No)e

THOUGHT CONTENTS:

De(*+io) Mi+i)ter-retatio)+:

atie)t ha+ -er+e&*tor8 2e(*+io) a)2 2e)ie+ a)8-er&e-tio)a(

ee(i)#+ of I)f(*e)&e:

ee(i)#+ of a++iit8:De-er+o)a(i@atio)+:

H8-o&ho)2ria+:

Ha((*&i)atio)+:

reo&&*-atio):

,+e++io)+/hoia+: No)e

,er Determi)e2 I2ea+: No)e

S*i&i2a( ho*#ht+: Not +*i&i2a(

%e-etitie Dream+:De+&rie2 the+e i) 2etai(+6

ORIENTATION:(a&e: atie)t i+ a(e a)+>er a)2 re&o#)i@e >here

ime: atie)t <)o> >hat time i+ it

er+o): atie)t &a) re&o#)i@e -eo-(e >e((

8/11/2019 En. H Psy


MEMORY:

%emote Memor8: oo2

%e&e)t Memor8: oo2

Imme2iate Memor8: oo2

Co)fa*(atio): oo2ie Mi)*te+ Memor8 e+t: atie)t &a) rememer >e((

INFORMATION +OCABULARY:

"+timate I)te((i#e)&e !ee(:

ABSTRACTION:

roer+ e+t:

ATTENTION +CONCENTRATION:

Di+tra&tii(it8:

Seria( See) e+t: U)a(e to &om-(ete +eria( See) te+t -atie)t &(aime2

that hi+ mathemati& &a(&*(atio) i+ -oor.Di#it S-a):

,UDGEMENT:

INSIGHT: No i)+i#ht

PHYSICAL E-AMINATION:

GENERAL:

em-: 3.4 C

*(+e %ate: 5%e+-. %ate: E0

B/: 110/=E mm/h#

CARDIO.ASCULARSYSTEM:

; Norma( heart eat rate; No a)orma( +o*)2 fo*)2 2*ri)# a*+&*(tatio); No m*rm*r

RESPIRATORY SYSTEM: ; Che+t e-a)2 )orma(; No a)orma( (*)# +o*)2 -ro2*&e

; Breathe >e((

ABDOMEN: ; Norma(; No -ai) or or#a)ome#a(8 2*ri)# -a(-atio)

CENTRAL NEROUS

SYSTEM:

8/11/2019 En. H Psy


8/11/2019 En. H Psy


LAPORAN REFLEKTIF:Beri<a) <ome) me)#e)ai -eme(aFara) im-(i<a+i -e)#*r*+a) <e+ i)i 8a)# te(ah2i-ero(ehi 2ari-a2a -e)#<aFia) <e+ i)i6

e)#*r*+a) <e+: Bai<

Mem*a+<a)

!emah

%ef(e<+i -eme(aFara) 8a)# 2i-ero(ehi 2ari-a2a -e)#<aFia) <e+ i)i:

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8/11/2019 En. H Psy



FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING

Na(a Pe&ati/: 0000000000000000 No1 Mat#i2: 000010001

Ta/3n: 00 Se(este#: 000 Ka4asan Pene(5atan: 1110000000000

Bi&1 Pe#2a#a !a6a#an S2o# Catatan

1 Bio2ata -e+a<it 7

E Ri4a'at Pesa2it:

E.1 A2*a) UtamaE.E SeFarah e)8a<it i)iE.3 SeFarah Dari Ah(i e(*ar#aE.4 SeFarah e(*ar#aE.5 SeFarah er+o)a(!ai)E 8a)# er<e)aa)6

87

3 Peni&aian Sta3s Menta&:3.1 ea2aa) Am i)#<ah !a<*3.E er&a<a-a)3.3 Moo23.4 emi<ira)3.5 ,rie)ta+i

3. Memori3.= InformationVocabulary & Abstraction3. Attention & Concentration3.9 Judgement & Insight

87

4 Pe(e#i2saan Fi9i2a&:4.1 emeri<+aa) Am4.E a)2a;ta)2a 7ita(4.3 e-a(a "/"N4.4 Da2a Ja)t*)#64.5 Da2a ar*;-ar*64. A2ome)4.= Si+tem Saraf 4. A)##ota Ata+ Ba>ah4.9 !ai);(ai) +e-erti #e)ita(ia re<t*m 2((6

;

5 %i)#<a+a) e)em*a) (i)i<a( 7

Dia<nosis:.1 Dia#)o+i+ Seme)tara.E Dia#)o+i+ ere@aa)

7

= Pen<3#3san:=.1 e)#e)2a(ia) a>a(=.E Uat;*ata)=.3 e)Fa#aa) <eF*r*ra>ata)

8;

!a-ora) ref(e<tif 7

,UMLAH ;;

a)2ata)#a) emeri<+a : $$$$$$$$$$$$.$$$$$

8/11/2019 En. H Psy


Nama : $$$$$$$$$$$.$$$$$$

ari<h : $$$$$$$$$$$$$$$$$


SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION

Na(a Pe&ati/: 0000000000000000 No1 Mat#i2: 00001000111

Ta/3n: 00 Se(este#: 000 Ka4asan Pene(5atan: 1110000000000

Bi&1 Pe#2a#a !a6a#anPELAKSANAAN

S2o# CatatanBai2

Me(3as2an

Le(a/

1eme)ta)#a) io2ata-e+a<it 8a)# te-at 2a)(e)#<a-

1

Eeme)ta)#a) ri>a8at-e+a<it 8a)# (e)#<a-

E

3

Me(a<*<a) -e)i(aia)+tat*+ me)ta( 8a)#(e)#<a- 2a) re(ea)2e)#a) te-at

3

4Me(a<*<a) -emeri<+aa)fi@i<a( 8a)# (e)#<a- 2a)re(ea) 2e)#a) et*(

1

5Ca2a)#a) 2ia#)o+i+ 2ia#)o+i+ -ere@aa)8a)# te-at

1

eme)ta)#a)-e)#*r*+a) -e+a<it 8a)#te-at 2a) (e)#<a-

E

,UMLAH ;

S2o#: 001111111110 = ;;> ? 11111111111111111111111111> ;

a)2ata)#a) emeri<+a : $$$$$$$$$$$$.$$$$$

Nama : $$$$$$$$$$$.$$$$$$

ari<h : $$$$$$$$$$$$$$$$$

en. h psy

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