PSYCHIATRIC SHEET

IDENTIFICATION DATA:

The patient is a single muslim male named Mahmoud Fathi Alkafrawy, aged 25 and unemployed. He
lives in Al-mahalla. The place of interview is at hospital. The source of referral and information is his
father. The cause of referral is for diagnosis and treatment. The patient came as compulsory admission.

COMPLAINT:

From the father:

- Since 1 month, patient starts to talk to himself

- He saw people talk to him [visual hallucination]
- He said people annoyed him
- He said someone walking on him during sleeping [pressure, deep, proprioception]
- He said car wants to attack him
- He makes trouble with people easily [physical and verbal aggression]
- He doesn’t sleep [insomnia]
- During winter, he took off his clothes and go out only with inners [disorganized behavior]. The
reason because patient felt chest tightness and took off the clothes in attempt to release the
stress.

From the patient:

- Someone talk to me [auditory hallucination]

- “I come involuntary, I’m not ill” [no insight]
- He heard jin during swimming and that caused water enters his nose [delusion]
- He saw people wearing white clothes [visual hallucination]
- He is admitted because he feels dizziness
- Jin wants to attack and hurt him.

HPI:

The condition starts 5 years ago, during examination, he started to talk to himself. He talks to himself in
his room for 1 week and go out of the room just to eat and to go to bathroom. He didn’t take shower.
He also ignores his personal grooming and hygiene. He took off his clothes and didn’t feel cold during
winter. He spits in front of people. He didn’t sleep for 3 days and if he sleeps he only sleeping for 2
hours. He was swimming with his friends then feel suffocation as if someone is choking him. He believes
that its jin’s doing. [the patients mistook the sound of him choking/aspirate with the sound of jin].
Patient sought medical treatment when his 1 attack 5 years ago and partially improved then he got ill
again. Treat with ECT and improved. The patient is in remitting / relapse course. The precipitating factor
is examination.

PAST HISTORY:

NO functional impairment.
PERSONAL HISTORY:

A- Early development (prenatal, perinatal and postnatal) : no abnormal data

B- School history:
- Faculty of law
- Good achievement before has the disease
- Then, 2nd year  he left law school due to repeated absence
- He didn’t come to exams  repeated failing
C- Occupational history: worked at clothes factory
D- Emotional history:
E- Sexual history:
F- Marital history:
G- Military history:
- Has certificate in military forces
- But doesn’t has to attend due to the illness
H- Legal history:
I- Habits: heavy smoker since 1 year ago (2box/day)

PERSONALITY BEFORE THE ILLNESS (PREMORBID PERSONALITY)

I. Social relations: sociable [before illness]

II. Intellectual activities and interests: no specific interest
III. Affect: euthymic
IV. Character: extrovert
V. Energy: energetic

FAMILY HISTORY:

1. Parents:
- Mother: Nagwa Ahmed Abdel Ghaffar, 45, housewife
- Father: Fathi Al-kafrawy, 57, retired(factory worker)
2. Siblings:
- Naglaa, 26, has diploma, housewife with 2 children
- Ahmed, 20, not educated, factory worker
3. Home atmosphere: calm and no trouble
4. Family diseases: +ve consanguinity

EXAMINATION:

A- PRESENT MENTAL STATUS EXAMINATION:

1- Consciousness: conscious
2- General appearance and behavior: well dressed
3- Talk: poverty at speech(minimal)
- Stream: average
- Expression: neologism, word salad
4- Mood: irritable
- Expression: apathy
 - Expression: not depressed, average
5- Perception: only auditory hallucination
6- Thought: delusion of persecution
7- Orientation: oriented
8- Memory: intact
9- Attention and concentration: attentive, concrete thinking
10- General information: average
11- Intelligence: average
12- Insight: poor
13- Judgement: poor

INVESTIGATIONS: -ve drug screen

DIAGNOSIS:
A case psychotic disorders SCHIZOPHRENIA
MANAGEMENT:

1. ANTI PSYCHOTIC
2. ECT
3. PSYCHOEDUCATION
4. HOSPITALIZATION (if dangerous to society)
5. PSYCHOTHERAPY

AFTER DR MAI ASKED:

- Only auditory hallucination

- Conversation with insulting
- Deny someone walking on him
- My son is intelligent, the only educated amongst his sibling [the father believes that his son will
become the pillar of the family but then, the disease came and he believes this is SIHR doing]
- So, the father cant accept the fact and insisted to ask help from sheikh, in the process, the
patient stop taking medication and relapse occur
- Patient not taking any drugs [proved by drug screen test]
- Never hospitalized before
- Patient has chest tightness  unbutton his clothes
- Only 3 exacerbations, after treatment, 5 ECT last year
- Have to shift to long acting treatment
- His parents are cousin
- The youngest is a spoiled child and doesn’t want to study
- Mse: apathy, the patient said he feels average