PARTICULARS OF PATIENT

Name: Sharan bin Nayan

NRIC:
Age: 41 yo
Sex: male
Ethnic group: kadazan jawa
Religion: Islam
Occupation: self employed(tukang urut)
Marital Status: single
Address: Kg Petagas, KK
CHIEF COMPLAINT and HISTROY OF PRESENTING ILLNESS
He was brought by his parent due to his change of behaviour and poor sleep for
abt 1 weeks duration. he has mental illness since 1995 and on treatment since
1997. He still on follow up at KK Putatan. His last visit at 17 Decem 2015. He is
on IM Flupentixol 40mg monthly.
On the past a week ago, his mother noted change of behaviour of her son. He did
an abnormal gesture mentalaah movement late at night until disturbing other
people sleeping. He not sleeping at night and no aggressive behaviour noted.
Otherwise, his appetite and weight is normal. Sometime he felt that the
television talked about him and his mother and told that it was mention in the
parlimen meeting. He also believed that there is someone trying to harm him. He
said the person is his business partner which may jealous about him. He said he
saw the person doing some black magic to his drink and claimed that he felt
unwell since he drink the drink. He said he will recite some recitation from Quran
which help him felt well and still do it now and claimed if he leave to recite it, he
will get sick.
He reported that he currently studying under Guru Jin. This guru jin came to his
house, talk to him and showed how to make a perfume from special flowers. He
loved studying under him. He also can see the figure of the guru jin. It is a big
person, wide red eyes, dark eye and usually wearing green jubbah. Prove to the
teaching, he went out from his house to look for the flowers. However, he
created any public noisence. He denied of having any special power. He has
increase goal directed activity as he ambitious for the perfume business after he
discharge. He denied of decreased in mood and not feeling of worthless, useless
and hopeless.
According to his mother, prior to admission, his eldest brother want to hit him
with metal rod but not truly hit due to his talkativeness.in 1998, he had suicidal
attempt where he want to jump from the apartment building. Otherwise, he
claimed not having any suicidal though or attempt.

PAST PSYCHIATRIC HISTORY

This is the 1st admission. Previously he had been follow up at HMBP for schizo
since 1997. He had poor compliance to medication because sometime he not
going due to busy of his business.
PAST MEDICAL HISTORY
He had no known medical illness
he had no surgery before
FAMILY HIST
His mother had gout, hypertension, and dyslipidemia. His grandmother on
maternal side has psychiatry problem. others are all healthy. There is no drug
use or alcohol use in the family. he lived with his family in double storey house
with good electrical and water supply.
He claimed had good support from his family. He ables to socialize well the
neighbour and family. not having any problem with them. Economy status for the
family come from his business and the pencenfrom father as father worked as
policeman previously.
PERSONAL HISTORY
He has been giving birth through spontaneous vaginal delivery at full term at
Queen Elizabeth hospital. He had normal milestone. There is no childhood illness.
he had many friend since child until now. He had no problem in meeting new
friend. He is good child and no discipline issue
He has been completed education until collage. His achievement in SPM is
pangkat 2(pass) and SRP/PMR is credit (pass). He said he taking an course of
traditional medicine and given with certificate for that. He used to work as
promoter at beach hotel and free duty shop for 5 years. He alse got better work
which is in the ShangRai Hotel for 5 years. Currently, he is self employed. He had
business as tukang urut at kampong Air and night market. He satisfied in
working. He is single and not having any girlfriend. He is a good child
PREMORBID PERSONALITY
He is a talkative person. His hobby is going to sea, memancing
He smokes 1pack/day and told that the 1pack/day is only finish as he shared with
his friends. He smokes since2/3 years. He took alcohol for about 2 months and
stopped. Currently, he not taking alcohol anymore. According to his mother, he
had no history of drug use.
MENTAL STATE EXAMINATION
General Appearance: 41 years old thin, dark gentleman wearing in hospital
pajama. He appears appropriate with his age. he has good personal hygiene.

Behaviour/ Attitude: he is cooperative and rapport is established. He has good

eye contact. There is no guarded and suspiciousness on him. He has no
mannerism and motor activity.
Speech: he can speak spontaneously with regular rate and normal tone.
Sometime he speaks irrelevant .otherwise, he has no repetition in speech., or
pressured speech.
Though Form: he has no flight of idea, looseness of association, and thought
block.
Mood: he has euthymic and happy mood
Affect: he has congruent affect and appropriate. He has broad affect as his facial
expression can show when he is happy and upset when he tells about something
happy or upset
Perceptual Disorders: he had auditory hallucination, visual hallucination and
tactile . auditory hallucination is 2nd person as he can communicate with and the
voice is men voice. he alse heard many voices other than the Gruu jin. Visual
halluncaiton where he can give figure of guru jin and others. Tactile hallucination
whre he can feel when the others touch and play with him. He is very happy to
have them.
Thought Contents: he has persecutory delusion and delusion of religion. He has
no obsession, phobia, or negative though.

COGNITIVE ASSESSMENT
Orientation: good orientation
Memory: has good memory. Can recall back the immediate, recent, remote and 5
minute memory
Attention and concentration: good at and conct. Can do well in serials 7s, 3s,
digit span.
Intelligence: good intelligence. He can answered all general knowledge (name of
state of Sabah and prime ministers name), proverb (panajng tangan, sikit-sikit
lama-lama jadi bukmentit), abstract similarities and concrete similarities
Judgement: good judgement
insight: poor insight as he think the hallucination is a normal thing

PHYSICAL EXAMINATION
FORMULATION:
PROV. DIAGNOSIS:

DIFF. DIAGNOSIS:
RISK ASSESSMENT
INVESTIGATIONS
TREATMENT PLAN: