FK UKI and FK UGM

I.PATIENT S I DENTITY
Name Age Gender Address Occupation Marital status Religion Last education Alloanamnesis Name Age Relation : Tn.MR : 45 years old : Male : Depok, Sleman Yogyakarta : Unemployed : Not Married : Muslim : Barchelor Degree : Mr. D : 27 years old : Brother in law

II.C HIEF

COMPLAINT

Not able to sleep in 2 days

History of illness
Not able to sleep Patient was restles Poor anger management (unreasonable angry) Threaten his father Talk to him self, and irritable. Poor grooming, patien no desire to take a bath

2 days ago

15 years ago

Uncontrelled Rage Not working

PAST ILLNESS HISTORY

Psychiatry history First psychiatry disorder about 15 years ago. Patients had a history of outpatient treatment and taking medication but medication is not adequate. General medical history Hypertension (-) Head injury (-) Asthma (-) Febrile seizure (-) Hepatitis A (+) Drugs and alcohol abuse history and smoking history Alcohol consumption(-) Tobacco consumption (+) Drug use (-)

PRENATAL DAN PERINATAL

There is no data about his mother condition when she is pregnant. Patient delivered through normal delivery, at term

E ARLY C HILDHOOD P HASE (0-3 Y EARS O LD ) (C ONTINUE )

Psychomotoric (NO VALID DATA)
Normal growth and development in terms of head, rolling

over, sitting, crawling, standing, holding objects in his hand, putting everything in his mouth, holding objects in his hand, begin walking is unknow.
Psychosocial (NO VALID DATA)

There were no data of patient when started smiling,startled by noises, first laughed.

Communication (NO VALID DATA) Patients first words begin is unknow.

Emotion (NO VALID DATA)

There were no valid data how patient showed normal reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (NO VALID DATA)

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.

I NTERMEDIATE C HILDHOOD (3-11 Y. O )

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.

Communication

There were no valid data on socialization.

Emotional

No valid data on patients adaptation under stress

Cognitive

There were no valid data in terms of grades in school

L ATE C HILDHOOD & T EENAGE P HASE

Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpits and pubis, etc

Psychomotor

There were no valid data of favourite hobbies or games

Psychosocial

Begin to have less friends Patient claimed to have relationship with opposite gender.

Emotional

Patient expressed to mother regarding any problems.

Communication

No valid data.

A DULTHOOD
Educational and Occupational History : patient s last education is barchelor degree. Marital status : not married Legal History : Never been arrested or caught by police. Social Activity : have a normal social activity. Current Situation : Living with his father. Religious History : Fair

FAMILY H ISTORY

There is no history in his family.

P SYCHOSEXUAL

HISTORY

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

G ENOGRAM

:Female :Male

: Patient : RIP

Socioeconomic history
Validity

Economic scale: low

Alloanamnesis : valid Autoanamnesis : valid

P ROGRESSION
symptom

OF I LNESS

1997

2012

Role function

 III Mental State (13-12-2012)

Appearance :

Adult man, appropriate according to age, dressed

inappropriately

State of Consciousness Clear

Speech:

Quantity Quality

: Increased : normal

B EHAVIOUR
Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism
Command automatism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

ATTITUDE

Cooperative

Non-cooperative
Indiferrent Apathy Tension Dependent

Active
Passive

Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility

E MOTION
Mood
Dysphoric Euphoria Elevated Expansive Irritable Cant be assesed

Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile

D ISTURBANCE OF PERCEPTION
Hallucination Illusion Auditory Visual Olfactory Gustatory Tactile Somatic

Auditory Visual Olfactory Gustatory Tactile Somatic

T HINKING
THOUGHT PROGRESSION

Quantity

Quality Irrelevan answer Incoherence Flight of idea Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality Tangential Verbigrasi Perseverasi Sound association Word salad Echolalia

Logorrhea Blocking Remming Mutisme Talk active

T HOUGHT P ROCESS
CONTENT OF THOUGHT

Idea of reference
Preokupasi Obsesi Fobia

Delusion of nihilistik Delusion of control Delusion of influence Delusion of passivity

Delution of persecution Delusion of perception Thought of echo Delution of Reference Thought of insertion/withdrawal Delution of envious Thought of broadcasting Delution of hipokondri

T HOUGHT

FORM

Form of Thought

Realistic Non Realistic Dereistic Autistic

SENSORIUM

AND COGNITION

Level of education General knowledge

: enough : hard to be assessed

Orientation of time

: enough

place : enough people : enough

working/short/long memory: enough

Writing and reading skills Visuospatial Abstract thinking Ability to self care

: enough : not evaluated : not evaluated : poor

Impulse control when examined

Self control : enough Patient response to examiners question: enough

Insight

Impaired insight Intelectual Insight True Insight

IV. PHYSICAL EXAMINATION

I NTERNAL S TATUS

Conciousness : compos mentis

Vital sign:
Blood pressure Pulse rate Temperature RR: : 130/90mmHg : 88x/mnt : afebris : 18x/mnt

Head Eyes

: normocephali : anemic conjungtiva -/-, icterik sclera -/-, pupil isocore

Neck
Thorax:

: normal, no rigidity, no palpable lymphnode

Chor : S1 and S2 Sound and normal Lung : vesicular sound, wheezing -/-, ronchi-/

Abdomen : Pain - , peristaltic normal, thympany sound Extremity : Warm acral, capp refill <2

N EUROLOGICAL

STATUS

Motoric

: not tested

Physiological reflex : not tested Pathological reflex : not tested

SIGNIFICANT FINDING RESUME

Onset 15 years ago patient : Rage 2 days ago patient: Not able to sleep Rage Angry threaten his father Mental Status Euphoria mood Inappropriate affect Auditory Halucination Delusion of control Thought of withdrawal Loosening of assosiation Impairment Role function: inability to work. Spare time: talk to himself Psychosocial : fair Ability to self care : poor grooming

D IFFERENTIAL D IAGNOSE

F20.0 Paranoid Schizophrenia F25.0 Schizoaffective manic type

VII. DIAGNOSTIC FORMULATION

M ULTIAXIAL D IAGNOSE
Axis I : F20.0 Paranoid Schizophrenia

Axis II
Axis III

: Delayed
: No concomitant medical condition

Axis IV
Axis V

: Not working
: GAF 40 - 31

M ANAGEMENT

THERAPY

Hospitalized : threatening his father. Medication -Initial Therapy: Lodomer 1 amp IM -Room: Risperidon THP 2 x 2mg 2 x 2mg (PRN)

T HERAPY
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.

Ad vitam Ad functionum Ad sanationum

: Ad Malam : Ad Malam : Ad

Thank You