Tuesday , July 31 th,2012 Supervisor : dr Sabar P Siregar Sp.

Kj

Name Age Gender Address Occupation Marriage status Religion Last education graduated)
Alloanamnesis Name Age Relation

: Mr. H : 45 years old : Male : Pingit : Unemployed : marriage : Kristen : junior high school (not

: Ms. E : 48 years old : Patients wife

Threat his wife harmfully since 5 ago

 Talk to him self

1 months ago

Self giggling
Self withdrawal Crying without any cause Poor grooming Heard a strange noise

Threat his wife harmfully Destroying stuff in home such as door about 5 times

5 days ago

Talk to him self Self giggling headache Self withdrawal Crying without any cause Poor grooming Heard a strange noise

Psychiatry history 28 years ago 1st time look werd 1984 he was hospitalized in RSJ (Unknown) He was hospitalized in RSJ Prof Soerojo 15 times and cured. (1993,1998,1999,2001, 2002, 2003, 2004, 2005, 2006 , 2007, 2008, 2010,2011, 2012. He doesnt want to consume the drugs because he pretend that hes healthy

General medical history Hypertension (+) Head injury (-) Convulsion (-)

Drugs and alcohol abuse history and smoking history Alcohol consumption (-) Tobacco consumption (+) drug use (-)

PRENATAL AND PERINATAL HISTORY

Psychomotoric
There were no valid data on patients growth and development such as; first time lifting the head, rolling over, sitting, crawling, standing, walking-running, holding objects in her hand, putting everything in her mouth, holding objects in her hand

Psychosocial
There were no valid data on which age patient started smiling when seeing another face, startled by noises, when the patient first laugh or squirm when asked to play, nor playing claps with others

Communication
There were no valid data on when patient started saying words like mom or dad, or talks.

Emotion
There were no valid data of patients reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive
There were no valid data on which age the patient can follow objects, recognizing her mother, recognize her family members. There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders.

Psychomotor
No valid data on when patients first time riding a tricycle or bicycle, if patient ever involved in any kind of sports.

Psychosocial
There were no data on patients gender identification, interaction with her surroundings There were no data on when patient first entered primary school, how well patient handles seperation from parents, how well she plays with new friends on first day of school

Communication
There were no valid data regarding patients ability to make friends in school, and how many friends patient have during her schooling period.

Emotional
No valid data on patients adaptation under stress, any incidents of bedwetting were not known.

Cognitive
No valid data on patients achievement in school, how well patient;s reading ability and grades.

Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpits and pubis, etc No valid data if patient had any favourite hobbies or games, if patient involved in any kind of sports. No valid data if while growing up did he make many friends, how well patient make any friends and how much friends. No valid data on when and how patients relationship with different gender, if patient ever had any relationship with the opposite gender. No valid data if patient ever told friends or family regarding any problems. No valid data if patient attempted to break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugs No valid data on how well the relationship between patient with parents and other family.

Psychomotor

Psychosocial

Emotional

Communication

Educational history
Junior High School (not graduated)

Current situation
He lived with his wife

Occupational history
Patient has no work

Religion history

He never prays and not religious

Marriage status
Legal history

Married No data

Social activity
He has no friends, never pray, only want to talk with his parents

Patient is the 3Rd child from 4 siblings He stayed with his parents In his family no one have the same symptom

Patient psychosexual history is appropriate of his gender and attracted to woman

Patient Man Woman

Socioeconomic history

Economic scale:mild

Validity

Alloanamnesis Autoanamnesis

: valid : valid

symptom

1984

1993

1998

1999

Role function

symptom

2001

2002

2003

2004

Role function

symptom

2005

2006

2007

2008

Role function

symptom

2010

2011

2012

Role function

III Mental State

Appearance :
Man, appropriate according to age, dressed in

blue with stripes and brown jeans

State of Consciousness Clear

Speech:
Quantity : Increase
Quality : Normal

Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism

Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

Non-cooperative Indiferrent Apathy Tension Dependent Active Passive

Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility

Mood
Euthymic Dysphoric Euphoria Elevated Expansive Irritable Cant be assesed

Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile

Hallucination Auditory (+) Visual (-)

Illusion Auditory (-)

Visual (-)
Olfactory (-) Gustatory (-)

Olfactory (-)
Gustatory (-) Tactile (-)

Tactile (-)
Somatic (-)
Derealisation (-)

Somatic (-)

Quantity
Logorrhea
Blocking

Quality
Irrelevant answer
Incoherence

Flight of idea
Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality

Remming
Mutisme Talk active

Tangentiallity
Verbigration Sound association Perseveration Word salad

Idea of reference Preokupasi Obsesi Fobia Delution of pursued

Delusion of magic-mistic

Delusion of control
Delusion of influence Delusion of passivity Delusion of perception Thought of echo Thought of insertion/withdrawal Thought of broadcasting

Delution of suspicious
Delution of envious Delution of hipokondri

Form of Thought

Realistic Non Realistic Dereistic Autistic

Level of education : not enough General knowledge : enough Orientation of time : enough place : enough people: enough Working/short/long memory : enough Writing and reading skills : enough Visuospatial : enough Abstract thinking : poor Ability to self care : poor

Impulse control when examed

enough

Impaired insight

Insight

Intelectual Insight
True Insight

IV. PHYSICAL EXAMINATION

Conciousness : compos mentis Vital sign:

Head

: normocephali

Eyes anemic conjungtiva -/-, icterik sclera -/-, pupil

isocore

Neck : normal, no rigidity, no palpable lymphnode Thorax: Chor : S1 and S2 Sound and normal Lung : vesicular sound, wheezing -/-, ronchi-/Abdomen : Pain - , peristaltic normal, thympany sound Extremity : Acral temperature, capp refill <2

Motoric : normotonus, good coordination of movement Physiological reflex : +/+ Pathological reflex : -/: Delayed

Ro Thorax

 Onset: 1 month Though progression

ago : Stressor: be assested quantitativecant

Form of though

: Non realistic

Symptoms first occure since 5 days ago thretening to kill his wife Destroying stuff in home such as door about 5 times Talk to him self Self giggling headache Self withdrawal Crying without any cause Poor grooming Heard a strange noise

Disability (hendaya): occupation: unemployed Ability to self care : poor grooming spare time: talk to himself psychosocial : doesnt have anyone to accompany him to talk, so he decide to hospitalized Duration: 28 year ago

- Mood : eutimik - Affect : inappropriate - Speech :

Thought Progression: talk attive Thought process : Delusion of persecution Auditoric hallucination Thought process : non realistic

 F.

20.0 Paranoid Schizophrenia Disorder F. 25.0 Schizoafective Dissorder Manic Type

VII. DIAGNOSTIC FORMULATION

Axis I Disorder Axis II Axis III Axis IV Axis V

: F. 20.0 Paranoid Schizophrenia : : : : Paranoid hypertension grade II No stressor GAF 20-11

Hospitalized Medication Initial Therapy: ER : - Diazepam 10 mg/2 CC (IV) - Lodomer 5mg (IM) Room : - Tab Haloperidol 2x 5mg (oral) - Captopril 3x25mg

Hospitalized Family education Explain to his family about this patient mental disorder Describes steps of treatment Family must maintain the patients drugs consumption and routine doctor consultation , so it will increase the efficacy of treatment Family must keep in touch with patient intensively, so the patient will not feel lonely.

Ad vitam Ad functionum Ad sanationum

: malam : malam : malam

Thank you