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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

patien no desire to take a bath 2 days ago 15 years ago • Uncontrelled Rage • Not working . •Poor grooming. and irritable.History of illness •Not able to sleep •Patient was restles •Poor anger management (unreasonable angry) •Threaten his father •Talk to him self.

• • • • 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 (-) . • Patients had a history of outpatient treatment and taking medication but medication is not adequate.PAST ILLNESS HISTORY Psychiatry history • First psychiatry disorder about ± 15 years ago.

PRENATAL DAN PERINATAL  There is no data about his mother condition when she is pregnant. at term  . Patient delivered through normal delivery.

putting everything in his mouth. first laughed.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.  Communication (NO VALID DATA)  Patient’s first words begin is unknow.  Psychosocial (NO VALID DATA)  There were no data of patient when started smiling.startled by noises. holding objects in his hand. begin walking is unknow. rolling over. . holding objects in his hand. crawling. standing. sitting.

recognize her family members. Emotion (NO VALID DATA)  There were no valid data how patient showed normal reaction when playing.  Cognitive (NO VALID DATA)  There were no valid data on which age the patient can follow objects. or understanding simple orders. frightened by strangers. when starting to show jealousy or competitiveness towards other and toilet training. recognizing her mother. .  There were no valid data on when the patient first copied sounds that were heard.

 Emotional  No valid data on patient’s adaptation under stress  Cognitive  There were no valid data in terms of grades in school .  Psychosocial  There were no data on patient’s gender identification. if patient ever involved in any kind of sports.I NTERMEDIATE C HILDHOOD (3-11 Y. O )  Psychomotor  No valid data on when patient’s first time riding a tricycle or bicycle.  Communication  There were no valid data on socialization.

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.L ATE C HILDHOOD & T EENAGE P HASE  Sexual development signs & activity  No valid data on when patient experience wet dream. .  Communication  No valid data. hair on armpits and pubis.

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

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 .

dressed inappropriately  State of Consciousness Clear  Speech: ◦ ◦ Quantity Quality : Increased : normal . appropriate according to age. III Mental State (13-12-2012)  Appearance : Adult man.

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 Can’t 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     .

wheezing -/-. thympany sound Extremity : Warm acral. icterik sclera -/-. no rigidity.  Head Eyes : normocephali : anemic conjungtiva -/-. ronchi-/  Abdomen : Pain . capp refill <2” . pupil isocore   Neck Thorax: : normal. peristaltic normal.. no palpable lymphnode Chor : S1 and S2 Sound and normal Lung : vesicular sound.

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 .

0 Schizoaffective manic type .0 Paranoid Schizophrenia F25.D IFFERENTIAL D IAGNOSE   F20.

DIAGNOSTIC FORMULATION . VII.

M ULTIAXIAL D IAGNOSE Axis I : F20.31 .0 Paranoid Schizophrenia Axis II Axis III : Delayed : No concomitant medical condition Axis IV Axis V : Not working : GAF 40 .

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 patient’s 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 .