Supervisor : Dr. Sabar P. Siregar, Sp.

KJ

I. Patient Identity
Name Age Sex gender Address Occupation Marriage status Religion Education Alloanamnesis Name Age Relation : : : : : : : :

: :

II. Psychiatric History

Chief Complaint:

History of present illnes

History of present illnes

Psychiatric History

General medical history

Drugs and alcohol abuse history and smoking history

Life history

Prenatal and perinatal Early childhood phase (0-3 tahun)

Intermediate childhood phase (3-11 tahun) Late childhood and teenager phase (1118 tahun)

Adulthood

Education history Occupational history

Marriage status

Legal History Social Activity Current situation

Religion history

Family history

Psychosexual history

Genogram

Socio-economy history

Validity
Alloanamnesis : Autoanamnesis :

Illnes Progression
Symptom

Role function

III. MENTAL STATE

Appearance State of conciousness

Speech :
Quality
Quantity

: :

Behaviour
Normoactive Hypoactive Hyperactive Echoplaxia Catatonia Active negativism Cataplexi Streotype 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

Physic contact
Yes/ No

Suitable/unsuitable
Sustainable/ unsustainable

Emotions

Euthymic Dysphoric Euphoria Elevated Expansive Irritable

Appropriate Inappropriate Restrictive Blunted Flat Labile

Mood

Afek

Disturbance of perception
Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)

Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)

Depersonalisasi :

Derealisasi :

halucination

illusion

Thought Process
Logorrhea Blocking Remming Mutisme

Quality

Quantity

Coherence Incoherence Flight of idea Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality Verbigration Sound association Perseveration Word salad Echolalia

Irrelevance answers

Thought process
content of thought
Idea of reference Delusion of passivity

Hypochondriac
Preoccupation Obsession Phobia Delusion of magic mystic Delusion of infidelity Delusion of control

Delusion of perception
Delusion of persecution Delusion of grandeur Delusion of reference Thought of echo Thought withdrawal Thought insertion

Delusion of influence

Thoght broadcasting
Thought control

Thought process
Realistic Non

Realistic Dereistic Autistic

Form of thought

E. SENSORIUM and cognition

Level of education : enough General knowledge : enough Orientation of people, time, place, situation: enough Working/short/long memory : no data Writing and reading skills : no data Visuospatial : no data Abstract thinking : enough Ability to self care : enough

F. Impulse control
Self control during assessment : Poor Patient response to examiners questions : Poor

G. Insight
Impaired insight Intelectual insight True insight

IV. Physical examination

A. Internal status
General state : good Conciousness : compos mentis Vital sign:

Blood pressure Pulse rate Temperature RR:

: 120/80 : 80 : 36,5C : 20x/mnt

Head : normocephali Eyes anemic conjungtiva -/-, icterik sclera -/-, RCL +/+, RCTL +/+, pupil isocore Neck : normal, no rigidity Thoraks:

cor : S1 and S2 sound clear and normal , reguler,

murmur - , gallop Lung: vesicullar sound, wheezing -, ronchi

Abdomen : slight tenderness (LUQ) Extremity : acral temperature , capp refill <2

B. Neurological status
Motoric : normotonus, good coordination of movement Physiological reflex : +/+ Pathological reflex : -/

V. Significant finding resume

 Deterioration

Role function Social function Sparetime managemet : poor Self care

: poor : poor : enough

Mood : dysphoric patient looks sad and loses her interest to things she love Disturbances of Perception

Thought process Thought progression : quantitative

qualitative
Thought content : Form of though :

Differential Diagnosis

Diagnostic Formulation

Multiaxial Diagnose
Axis I Axis II Axis III Axis IV Axis V

: : : : :

Therapy

Prognosis
Ad vitam Ad functionam Ad sanationam

: Ad bonam : Ad bonam : Ad bonam