Professional Documents
Culture Documents
Chief Complaint
Patient was brought to hospital for
aggressive behavior and assault
History:
- Patient was brought in by police accompanied by
his brother.
- His brother claimed patient became aggressive at
around 9pm today and he got punched over his
face and chest because his brother damaged the
door.
- Patient had became aggressive since 1 month ago
and his brother noted he has been smelling gum in
his room.
- His brother say patient has been sniffing gum for 2
years on and off, however for the past 3 months
patient has been sniffing more frequent
Family History
Father passed away due to complication
of diabetes mellitus ; mother passed
away due to breast cancer .
When asked how patient feel about the
passing of his parents, he was dysthymic
and he denies any suicidal thoughts or
feelings of worthlessness or hopelessness
He lived with his brother and their
relationship is good.
Personal History
Date of Birth: 17th August 1993
- Claims to have been born and raised in
Pahang for 6 years before family moved to
Kedah when his father was transferred.
- No abnormality during birth and no
childhood health problem
Education: Until Form 1 (incomplete
education)
Patient had poor performance in school
Marital Status: Single
Occupation: Previously was a security guard
- Has good relationship with employer and his
colleague
Social relationships:
- Good relationship with his friends
and family
Hobbies and Interests:
- Singing
- Reciting poetry
- Reading newspaper
Pre-Morbid Personality
- Patient was previously well when he
did not sniff glue, listen to order, never
aggressive, no abnormal behavior
noted.
Current circumstances:
- Patient is being cared for by his
brother
- Patient claims that once he can stop
his addiction sniffing, he wants to
return working.
- He has no significant other to care
for nor any financial responsibilities
Appearance:
Normal body build and height
Well kempt in hospital attire
Good hygiene
Mood:
- Mood congruent and euthymic
Affect: Appropriate
Speech:
Normal rate and normal quantity
Spontaneous
No neologism or word salad detected
Normal reaction time
Thought
Answered spontaneously and able to
elaborate the answer
Goal directed
Possession:
- There was no thought alienation,
withdrawal, insertion or broadcast
- No obsession or pre-occupation
Content:
Answered what was being asked
No preoccupation
Perception:
Patient has no problems with
perception
- He denies hearing any voices talking
to him, about him or comment on his
actions.
- He denies having any visual
hallucinations
Cognition
Orientation:
- Patient is orientated to time, place and
person
Memory:
- Immediate, short and long-term memories
are intact
Unable to assess attention and concentration
as he is difficult to interrupt or persuade
Unable to assess visuo-spatial organization,
calculation, abstraction or executive
functioning
Unable to assess intelligence
Insight:
- During first interview, patient has very
poor insight (may be due to psychosis)
- Insight improved on second ,third and
fourth interview
- On third interview, patient is aware of
his problem, understands that the cause
is due to his returning habit of
substance abuse, and understands the
impact it has to his life and his
surroundings. He even says he will try
to stop sniffing glue and break free from
addiction
Physical Examination
Inspection:
- Alert and conscious
- No attachments to his limbs such as
cannula, IV drips, etc
Vital sign:
BP : 110/72
PR : 81
Temperature: 36.9
Sp02: 99%