Professional Documents
Culture Documents
Patients Identity
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2.
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8.
Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status
: Mr. S
: 30 years old
: male
: Batang
: Unemployed
: Single
: Javanese
: Elementary
Family Identity
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2.
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Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status
: Mr. A
: 34 years old
: male
: Batang
: Employee
: Married
: Javanese
: S1
Reason brought to
hospital
Progression of Illnes
2014
Progression of Disease
2015
Patient get angry easily, rage often, wander and talk to himself
4 days ago
Often daydreaming
Easily offended
Easily angry
Talk to himself
Seeing ghost
1 day ago
Day of Admission
Patient was brought by his brother because his brother afraid the
patient can put others in danger
Psychiatric Illness
Hospitalized 1 year ago with the same symptom (11 days, patient
get better, didnt control to hospital)
General Illness
Substance Abuse
Family History
Physical Examination
Vital Sign
BP : 120/90 mmHg
HR : 90/min
RR : 24/min
Thorax
Cor
Lung
Abdomen
Extremity
Cranial
nerves examination:
CN I
: not assessed
CN II
: not assessed
CN V
CN VII
: not assessed
CN VIII
: not assessed
CN IX
: not assessed
CN X
: not assessed
CN XI
: not assessed
CN XII
: not assessed
: not assessed
Physiological reflex
Pathological reflex
Meningeal sign
not assessed
Cerebellum function
not assessed
Mental State
Examination
General appearance
A male, age 30 years old, appropriate to her age, and wearing good cloth, self
grooming enough
Consciousness
Clear
Orientation
Time
: good
People
: good
Place
: good
Situation : good
Behavior
Hypoactive
Hyperactive
Echopraxia
Catatonia
Negativism
Cataplexy
Stereotipy
Mannerism
Automatism
Command
automatism
Bizarre
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
Tremor
Floxilation
Loss of energy
Dischynesia
Muscle rigidity
Bradychynesia
Khorea
Convulsion
Dystonia
Aminia
Attitude
Cooperative
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Active
Infantile
Distrust
Labil
Rigid
Passive negativism
Stereotipy
Catalepsy
Cerea flexibility
Excited
Mood
Mood:
Euthymic
Elevated
Dysphoric
Euphoria
Expansive
Irritable
Affect:
Inappropriate
Restrictive
Blunted
Flat
Labile
Thought of perception
Halusinasi
Auditory (+)
Olfactory (-)
Visual (+)
Gustatory (-)
Tactile (-)
Somatic (-)
Undeferrentiated
(-)
Depersonalisation (-)
Ilusi
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Undiferrentiated (-)
Derealisation (-)
Thought progression
Kuantitas
Logorrhea
Talk active
Blocking
Remming
Mutism
Kualitas
Irrelevant answer
Incoherence
Flight of idea
Confabulation
Poverty of speech
Slow speech
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
Content of thought
Idea
of reference
Delusion of grandiose
Delusion of control
Delusion of influence
Obsession
Delusion of grandiosity
Phobia
Delusion of perception
Preoccupation
of being
guilty
Delusion
of persecution
Thought echo
Delusion
of reference
Thought insertion
Delusion
of jealousity
Thought withdrawal
Delusion
of hipochondry
Thought broadcasting
Delusion
of magic-mystic
Cant be assessed
Idea
of suicide
Form of thought
Realistic
Non realistic
Dereistic
Autistic
:
:
:
:
:
:
poor
poor
good/ good/ good/ good
impaired
poor
decrease
Insight
Impaired insight
Intellectual insight
True insight
A female 36 years,
Symptom:
Mental Status :
Impairment:
Talking to himself
Irritable.
Hit his mother and easily get
angry
Wandering
Heard voices and see ghost
Feel like being controlled
when he hit his mother
Behavior :
Hyperactive, bizzare
Attitude : Cooperative,
excited
Mood: Euphoria
Affect: inappropriate
Perseption: Auditory
and visual
hallucination
Thought
progression:Blocking,
Flight of ideas,
incoherent
Content of thought:
delusion of control
Form of thought of :
Non realistic
Insight: impaired
insight
Patient
cannot work
Patient
cannot
socialize
Patient can
be a thread
to the other
Syndrome
Impairment of socialization
Delusion of control
Auditoric hallucination
Visual hallucination
Sleep disorder
Hyperactive
Euphoria
Schizophrenia
syndrome
Depressio
n
Syndrome
Mania
Syndrome
Diagnosis Banding
F20.3
F25.0
Multiaxial Diagnosis
Axis
Axis
Axis
Axis
Axis
I
: R. 69 (diagnosis Axis 1 Tertunda)
II
: F.70 RM Ringan
III : IV : V : GAF 20 - 11
Management Planning
Hospitalization
Emergency Department
Inj. Diazepam 10 mg IV
Remission phase
Target therapy :
Inpatient management
Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy
Recovery Phase
Rehabilitation :
Find a hobby
Family Education
Dont push patient to understand the family, but his family that has
to understand him
Thank You