PSYCHIATRIC SHEET

Identification data:

The patient is a single muslim male named Eslam Mohd Farouk, aged 26 and worked as a mechanic. He
lives in Tanta. The interview placed at hospital. The source of referral and information is his father. The
cause of referral is for treatment.

Complaint:

From the patient:

- He complains people were looking and laughing at him

- He feels people were badmouthing and insulting him
- He told that there is people trying to attack him while he was riding his motorcycle
- Since 4 days ago, he believes that another patient talks behind his back
- Patient feels that people around him make mistakes towards him so, they are afraid of him

From the father:

- The patient complains people are insulting him while he was riding motorcycle
- The patient wants to be alone
- He smokes excessively
- He breaks everything in his apartment without significant reasons and beat his parents
- The patient also asked the father that why people were wearing white when in reality they don’t
- He also threatens others who hangs their clothes outside
- During attending a funeral, he said to his family, “if you are taking me there, it’s my funeral”

From the mother:

- He didn’t want to go work

- He sold motorcycle and spends money for eating and cannabis
- He wants to buy another motorcycle
- Someone strike his motorcycle accidentally but he thinks that the person wants to attack him
- Hallucination: he saw someone dead infront of him so he feels afraid
- He go to his roof and shout to his neighbors

HPI:

 Onset: from 1-2 years ago

 He didn’t want to go out from home as people look at him
 If people do anything, he thought they will harm him
 He said his arm is long
 He didn’t want to see anyone
 After that, he started doesn’t go to work
 Sometimes, he didn’t care about his hygiene.
 Precipitating factor: Work trouble
 Course and duration of symptoms: Progressive and 1 month
 Functional impairment: interrupted
  Previous treatment: he seeks medical advice but no treatment
 Analysis: patient has
- Delusion of persecution
- Physical and verbal aggression
- Visual and auditory hallucination

PAST HISTORY: No similar condition

PERSONAL HISTORY:

a- Early development (prenatal, perinatal and postnatal)

- No abnormal data
- No complication
b- School history
- Diploma of industrial
c- Occupational history
- Mechanic (motorcycle)
- Deliveryman
d- Emotional history: NO
e- Sexual history: NO
f- Marital history: NO
g- Military history: NO due to his bow leg
h- Legal history: NO
i- Habits:
- Smokers [2 packets per day]
- Cannabis [more than 1 year]

PERSONALITY BEFORE THE ILLNESS (PREMORBID PERSONALITY)

I. Social relations = sociable

II. Intellectual activities and interests = play football with his friends
III. Affect = euthymic (stable mood)
IV. Character = extrovert
V. Energy = energetic

FAMILY HISTORY

Parents:

- Father: Mohd Farouk, aged 56, a mechanic

- Mother: Zainab Saas Abd Rahman, aged 50, housewife

Siblings:

- Am, 23 yo, work at Carrefour

- Marwa, 17 yo, a student

Home atmosphere: calm and no travel

Family diseases: -ve family history and no similar condition

EXAMINATION

A- PRESENT MENTAL STATUS EXAMINATON:

1. Consciousness: conscious, alert
2. General appearance and behavior: normal
3. Talk: circumstantial [said unnecessary detail]
4. Mood: expression: irritable , experience: depress
5. Perception: delusion – persecution
6. Thought: auditory hallucination
7. Orientation: oriented
8. Memory: good
9. Attention and concentration: concrete thinking
10. General information
11. Intelligence: the patient is intelligent
12. Insight: full insight
13. Judgement: good

Provisional diagnosis:
A case of psychiatric disorder, most probably drug
abuse with physical aggression.
Treatment:

No hospitalization is required

A- Medication:
1- ANTI ANXIETY
2- MOOD STABILIZERS
3- PSYCHOTHERAPY
4- REHABILITATON