1. Saturday, 7 th December 2013 Supervisor : dr. Sabar P. Siregar, Sp.KJ

2.  Name: Mr. D Age: 23 years old Gender: Male Address: Magelang Occupation: unemployed Marriage status: not married Last education: Senior high school Patient Identity Alloanamnesis Name : Mr. K Age : 40 years old Relation : Brother

3.  Causes brought the patient to the hospital

4. 

5.  3 years ago Patient felt : - Angry and roughen without any reason - Sensitive He lost his job Social withdrawal : he won’t talk to the neighbor Presenting illness

6.  1 year ago Patient felt : Angry and roughen without any reason Sensitive Doesn’t taking medication Social withdrawal : he like to be alone Presenting illness

7.  3 months ago Patient felt : Angry and roughen without any reason Sensitive Felt suspicious to neighbor Impairment spare time Social withdrawal Bad grooming Presenting illness

8.  PRESENTING ILLNESS (CONT’D) The day patient brought to hospital - Often angry and roughen without any reason - More often felt suspicious to neighbor Doesn’t work Impairment spare time Social withdrawal Bad grooming

9.  Psychiatry history None General medical history Hypertension (-) Head injury (-) Convulsion (-) Asthma (-) Allergy (-) Drugs and alcohol abuse history and smoking history Alcohol consumption (+) Tobacco consumption (-) Drugs abuse (-) HISTORY OF PRESENT ILLNESS

10.  PRENATAL AND PERINATAL HISTORY  No significant abnormality medical conditions & nutritions during the mothers’s pregnancy.  No significant abnormality regarding patient’s birth and birth conditions.  Patient was borned in indigenous medical practitioner History of Personal Life

11.  Psychomotoric (No Valid Data)  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 his hand, putting everything in his mouth, holding objects in his hand Psychosocial (No Valid Data)  There were no valid data on which age patient started smiling when seeing anothers face, startled by noises, when the patient first laugh or squirm when asked to play, nor playing claps with others. Communication (No Valid Data)  There were no valid data on when patient started saying words like ‘mom’ or ‘dad’, or talks. Early Childhood Phase (0-3 years old)

12.  Emotion (No Valid Data)  There were no valid data of patient’s reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards othis and toilet training. Cognitive (No Valid Data)  There were no valid data on which age the patient can follow objects, recognizing his mothis, recognize his family members.  There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders. Early childhood phase ( cont’d)

13.  Psychomotor (No Valid Data)  No valid data on when patient’s first time play hiding, if patient ever involved in any kind of sports. Psychosocial (No Valid Data)  There were no data on patient’s gender identification, interaction with patient surroundings but the patient usual to isolate patient self.  There were no data on when patient first entered primary school, how well patient handles seperation from parents, how well he plays with new friends on first day of school Communication (No Valid Data)  There were no valid data regarding patient’s ability to make friends in school, and how many friends patient have during his schooling period. Emotional (No Valid Data)  No valid data on patient’s adaptation under stress, any incidents of bedwetting were not known. Cognitive (No Valid Data)  No valid data on patient’s achievement in school, how well patient’s reading ability and grades. Intermediate Childhood (3-11 years old)

14.   Sexual development signs & activity (No Valid Data)  No valid data on when patient experience wet dream, hair on armpits and pubis, etc  Psychomotor (No Valid Data)  No valid data if patient had any favourite hobbies or games, if patient involved in any kind of sports.  Psychosocial (No Valid Data)  While growing up patient make many friends, had much friends  Patient’s had relationship with different gender, had relationship with the opposite gender.  Emotional (Not Valid Data)  patient had no family regarding or any problems with others people.  Patient not break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugs  Communication (No Valid Data)  Well relationship between patient with parents and other family. Late Childhood & Teenage Phase

15.  StageBasic ConflictImportant Events Infancy (birth to 18 months) Trust vs mistrustFeeding Early childhood (2-3 years) Autonomy vs shame and doubtToilet training Preschool (3-5 years) Initiative vs guiltExploration School age (6-11 years) Industry vs inferioritySchool Adolescence (12-18 years) Identity vs role confusionSocial relationships Young Adulthood (19-40 years) Intimacy vs isolationRelationship Middle adulthood (40-65 years) Generativity vs stagnationWork and parenthood Maturity (65- death) Ego integrity vs despairReflection on life Erikson’s stages of psychosocial development

16.   Educational history ◦ Patient graduated from senior high school  Occupational history ◦ He does not employee since graduated and he lost his job after three month of his first job  Marriage status single  Legal history ◦ None  Social activity Patient is able to interact with the local community  Current situation ◦ patients living with his parents and brothers  Religion history A moslem, he prays daily Adulthood

17.   Patient is the 2nd child from 3 siblings.  There is no physichiatric disorder on his family Family History

18.   Patient psychosexual history is appropriate to his gender and behaves according to his gender. Psychosexual history

19.  Genogram Man Woman Patient

20.  Low Socio- economic history Alloanamnesis : valid Autoanamnesis : valid Validity

21. Progression of Ilness symptom Role function 3 years ago The day patient in 1 years ago3 months ago

22.   Appearance : Look man according to his age, wearing shirts and trousers, bad grooming  State of Consciousness Clear  Speech: ◦ Quantity: increase ◦ Quality: decrease Mental State (Saturday 7 th December 2013)

23.  Behaviour Hypoactive Normoactive Hyperactive (+) Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

24.  ATTITUDE  Cooperative  Non-cooperative (+)  Indiferrent  Apathy  Tension  Dependent  Active  Passive Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility Excitement

25.  Mood Euthymic Dysthymic Dysphoric (+) Euphoria Elevated Expansive Irritable Affect Appropriate Inappropriate (+) Restrictive Blunted Flat Labile (+) Emotion

26.  Disturbance of perception Hallucination Auditory Visual Olfactory Gustatory Tactile Somatic Illusion Auditory Visual (+) Olfactory Gustatory Tactile Somatic Derealisation (-)Depersonalisation (-)

27.  thought progression Quantity Logorrhea (+) Blocking Remming Mutisme Talk active Quality Irrelevant answer Incohisence Flight of idea Confabulation Poverty of speech Loosening of association Neologisme Circumstansiality (+) Tangentiallity Verbigration Sound association Perseveration Word salad Echolalia

28.   Idea of refference  Preokupasi  Obsesi  Fobia  Delusion of pursued (+)  Delusion of suspicious (+)  Delusion of reference  Delusion of hipokondri content of thought  Delusion of magic-mistic  Delusion of control  Delusion of influence  Delusion of passivity  Delusion of perception  Delusion of grandeur  Thought of echo  Thought of insertion/withdrawal  Thought of broadcasting

29.  Form of Thought Realistic Non Realistic (+) Dereistic Autistic Realistic Non Realistic (+) Dereistic Autistic

30.   Level of education: educated  General knowledge: good  Orientation of time/place/people/situation: Good/Good/Good/Good  Working/short/long memory: not examined  Writing and reading skills: not examined  Visuospatial: not examined  Abstract thinking: not examined  Ability to self care: Enough Sensorium and Cognition

31.  Bad Impulse control when examed Impaired insight (+) Intelectual Insight True Insight Insight

32.  Conciousnes : Composmentis Vital sign:  Blood pressure: 110/70 mmHg  Pulse rate : 70 x/mnt  Temperature : Afebrile  RR: 20 x/mnt Internal Status

33.   Head: normocephali  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 seconds Internal Status

34.   Motoric: Normotonus, good coordination of movement  Physiological reflex: Biceps +/+, Triceps +/+, KPR +/+  Pathological reflex: Hoffman-Tromer -/-, Babinski -/-, Chaddock -/-, Neurological status

35.  SIGNIFICANT FINDING RESUME  Onset: 3 years ago  Stressor: Problem with his job and his family always ask him about his job and make him feel cornered Symptoms - Angry and roughen without any reason - Show his genital - Lazy to work - Wondering - Social withdrawal - Bad quality grooming Mental Status Behaviour : Hyperactive, Mood : dysphoric Affect :Inappropriate,content of thought : Delusion of suspicious Delusion of persued Form of thought : non realistic Impaired insight Disability Social withdrawal Impairment spare time

36.  F20.0 Paranoid schizophrenia F22.0 Delusional presistant disorder Differential Diagnose

37.  Axis I: F20.0 Paranoid schizophrenia Axis II: R46.8 delayed diagnose Axis III: no diagnose Axis IV: Problem with his job and primary support group problem ( his family always ask him about his job and make him feel cornered) Axis V: GAF 30-21 Multiaxial Diagnose

38.  Hospitalization  Goal therapy is patient response with 50% of symptoms decreased  Hospital treatment plans should be oriented toward practical issues of self-care, quality of life, employment, and social relationships  To establish an effective association between patients and community support systems Therapy

39.  Psychosocial Therapy  Family-Oriented Therapies  Treat patient until 50% symptom gone  Explain to patient’s family about mental disorder. These are many factors cause the symptoms, such as biomolecules imbalance in the brain, so we need various aspects for the treatment  Don’t force the patient to understand the family instead vice versa  Treat the patient according to the family’s ability  Help the patient when he need it  Educate the family to encourage the communication and understanding

40.  ER  Lodomer inj 1 amp IM  Diazepam inj 1 amp IV Room  Risperidon 2 x 2mg Therapy

41.  Ad vitam : ad bonam Ad functionum : dubia ad malam Ad sanationum : dubia ad malam PROGNOSIS