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WEDNESDAY, 1 ST MEI 2013
Supervisor : dr. Sabar P. Siregar, Sp. KJ

PATIENT IDENTITY
Name
: Mr. S
Age : 31 years old
Gender
: Male
Address : Purworejo
Occupation
: Housemaid
Marriage status
: not yet married
Religion : islam
Last education : primary school
Alloanamnesis
Name
: Mr. S
Age : 41years old
Relation : brother

CAUSES BROUGHT THE PATIENT TO THE

HOSPITAL

Patient raged since

two years ago

PRESENTING ILLNESS

HISTORY OF PRESENT ILLNESS

HISTORY OF PERSONAL LIFE

PRENATAL AND PERINATAL HISTORY

No significant abnormality medical conditions &

nutritions during the mothers pregnancy.
No significant abnormality regarding patients birth
and birth conditions.
Patient was borned in indigenous medical
practitioner

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

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.

INTERMEDIATE CHILDHOOD (3-11

YEARS OLD)
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 him
surroundings but the patient usual to isolate himself.
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.

LATE CHILDHOOD & TEENAGE

PHASE

Sexual development signs & activity

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

Psychomotor
No valid data if patient had any favourite hobbies or games, if patient involved
in any kind of sports.

Psychosocial
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.

Emotional
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

Communication
No valid data on how well the relationship between patient with parents and
other family.

ADULTHOOD

FAMILY HISTORY
In his family no one have the same symptoms

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

GENOGRAM

Patient
Man
Woman
Dead

Progression of Ilness
sympto
m

2011

2012

Role function

Mental State (wednesday, 1 st MEI 2013)

Appearance :
Look man according to his age, wearing shirts and
trousers, poor grooming
State of Consciousness
cloudy
Speech:
Quantity: decrease
Quality: decrease

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism

Command automatism
Mutism
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
Excitement

EMOTION

DISTURBANCE OF PERCEPTION

Depersonalisation (-)

Derealisation (-)

THINKING
THOUGHT PROGRESSION
Irrelevant answer
Incoherence
Flight of idea
Confabulation
Poverty of speech
Loosening of
association
Neologisme
Circumstansiality
Tangentiallity
Verbigration
Sound association
Perseveration
Word salad
Echolalia

CONTENT OF THOUGHT
Idea of refference

Delusion of magic-mistic

Preokupasi

Delusion of control

Obsesi

Delusion of influence

Fobia

Delusion of passivity

Delusion of pursued

Delusion of perception

Delusion of refference
Delusion of envious
Delusion of hipokondri

Delusion of grandeur
Thought of echo
Thought of insertion/withdrawal
Thought of broadcasting

Form of Thought

Realistic
Non Realistic
Dereistic
Autistic

SENSORIUM AND COGNITION

Level of education

: low

General knowledge

: low

Orientation of time/place/people/situation:
enough/enough/enough/enough

Working/short/long memory: enough

Writing and reading skills

: not examined

Visuospatial

: not examined

Abstract thinking

: not examined

Ability to self care

: poor grooming

INTERNAL STATUS
Conciousnes: compos mentis
Vital sign:
Blood pressure
Pulse rate
Temperature
RR

:
:
:
:

120/90 mmHg
96 x/mnt
37 C
20 x/mnt

 Head: mesocephali
Eyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil
isocor
Neck: normal, no rigidity, no palpable lymphnode
Thorax:
Cor: S1 and S2 sound and normal
Lungs: vesicular sound, wheezing -/-, ronchi-/ Abdomen: pain -, peristaltic normal, thympany sound
Extremity: acral temperature, cappillary refill < 2 second

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

SIGNIFICANT FINDING RESUME

Onset: 2 year ago
Stressor: Broke up with his girlfriend

DIFFERENTIAL DIAGNOSE
F20.00 paranoid Schizophrenia
F25.1 Schizoaffective depressive type

MULTIAXIAL DIAGNOSE
Axis I
:
Schizophrenia
Axis II
:
of axis II
Axis III
:
Axis IV
:
Axis V
:

F20.00 paranoid
R 46.8 Delayed diagnosis
Unidentified
Broke up with his girlfriend
GAF admission 20-11

THERAPY
Hospitalization
To establish an effective association between patients and community
support systems
Hospital treatment plans should be oriented toward practical issues of
self-care, quality of life, employment, and social relationships
ER
Lodomer inj. 1 amp IM
Room
Risperidon tab 2 x 2mg
Psychosocial Therapy
Family-Oriented Therapies
Cognitive Behavioral Therapy

PROGNOSIS
Ad vitam

: dubia ad bonam

Ad functionum

: ad bonam

Ad sanationum

: ad bonam

THANK YOU