I. Examination of Psychiatry History

Patient’s Identity

Autoanamnesis

Name : Mr. K

Age : 34 years old

Gender : Male

Address : Banyubiru, Purworejo

Occupation : Farmer

Marital status : Married

Last education : Junior High School (graduated)

Alloanamnesis

Name : Mr. H

Age : 47 years old

Relation : Uncle

Psychiatry History :

Autoanamnesis and alloanamnesis was obtained on 30th September 2013 in Emergency

Room at 20:00 pm, RSJ Prof. Soeroyo Magelang.

A. Chief Complaint : Grumpy

B. History of Present Illness

Approximately 2 months ago, patient was angry without reason, giggle and talk by

himself and sleep disorder. The patient had problem in role function, but good in social

relation, good self care, and good sparetime management.According to patient’s uncle,

before the onset of change about 3 months ago, patient had separated from his wife ago

because patient sufferred a financial loss and his wife leave him. The patient had asked

his wife to be reconciled, but his wife reject.

One month ago, the patient had sleep disorder (hard to initate sleep), wandering alone,

angry without reason to other people around him, low apetite, giggle and talk by

himself. The patient still worked as clove merchant, but he was poor in role function

and sparetime management.

Day of admission, the patient was brought by his uncle because he was grumpy, too

easily offended and disturbing his neighborhood, had sleep disorder (hard to initate

sleep), wandering alone, low apetite, giggle and talk by himself. The role function,

social function, sparetime management and self care was poor. When his uncle brought

him to RSJS Magelang, his uncle was lied to him, so the patient became angry and got

berserk.

C. Past Medical History

1. Psychiatric History

In 2005 the patient was admitted to RSJ for similar symptoms. He was

hospitalization for 3 months and got some medicine from the hospital. The patient

had consume the medicine until 2008 and he stopped. From 2009 until 2013 the

patient did not consumed any medicine and he can do his daily activy likes normal.

2. General Medical History

No serious physical history. History of seizure or head injury (trauma) was denied.

3. Hystory of Alcohol, Smoke and Drug Use

Patient admit that he smoke cigarette since he was 18 years old.

D. History of Personal Life

1. Prenatal and Perinatal History

Patient was born in Purworejo, 28 March 1979 expected bitrh. No data on medical

conditions and nutritions during the mother’s pregnancy.

2. Early Chilhood Phase ( 0 -3 years old)

a. Psychomotoric (NO VALID DATA)

There were no valid data on patients growth and development such as:

First time lifting the head (3-6 months)

Rolling over (3-6 months)

Sitting (6-9 months)

Crawling (6-9 months)

Standing (6-9 months)

Walking-running (9-12 months)

Holding objects in her hand(3-6 months)

Putting everything in her mouth(3-6 months)

b. Psychosocial (NO VALID DATA)

There were no valid data on which age patient.

Started smiling when seeing another face (3-6 months)

Startled by noises(3-6 months)

When the patient first laugh or squirm when asked to play, nor playing

claps with others (6-9 months)

c. Communication (NO VALID DATA)

There were no valid data on when patient started saying words 1 year like

‘mom’ or ‘dad’. (6-9 months)

d. 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 other and

toilet training.

e. Cognitive (NO VALID DATA)

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.

3. Intermediate Childhood Phase ( 3 – 11 yeras old)

a. Psychomotor (NO VALID DATA)

No valid data on when patient’s first time riding a tricycle or bicycle, if patient

ever involved in any kind of sports

b. Psychosocial (NO VALID DATA)

No valid data on patient interaction with his surrounding, no valid data on

when patient first entered primary school, on how well patient handle

seperation from parent, how well he play with his new friend on first day

school.

c. Communication (NO VALID DATA)

No valid data regarding patient ability to make friends at school and how many

friends patient have during his school period

d. Emotional (NO VALID DATA)

No valid data on patient’s adaptation under stress, any incidents of bedwetting

were not known.

e. Cognitive (NO VALID DATA)

No valid data on patient’s cognitive.

4. Late Childhood and Teenage Phase ( 11 – 18 years old)

a. Sexual development signs & activity (NO VALID DATA)

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

b. Psychomotor (NO VALID DATA)

No data if patient had any favourite hobbies or games, if patient involved in

any kind of sports.

c. Psychosocial (NO VALID DATA)

Patient had never been told the parent about patient friend.

d. Emotional (NO VALID DATA)

No valid data on patients reaction on playing, scared, showed jealously or

competitiveness.

e. Communication (NO VALID DATA)

No valid data on how well the relationship between patient with parent and

other family.

5. Aldulthood History

a. Educational History

unior high school (graduated)

b. Occupational History

Clove merchant

c. Marital Status

Married in 2006, but separated from his wife.

d. Criminal History

No

e. Social Activity

Before disorder was normal

f. Religious History

Pray not routinely.

6. Psychosexual History

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

Erikson’s stages of psychosocial development

Stage Basic Conflict Important Events

Infancy

(birth to 18 months)

Trust vs mistrust Feeding

Early childhood Autonomy vs shame and doubt Toilet training

(2-3 years)

Preschool

(3-5 years)

Initiative vs guilt Exploration

School age

(6-11 years)

Industry vs inferiority School

Adolescence

(12-18 years)

Identity vs role confusion Social relationships

Young Adulthood

(19-40 years)

Intimacy vs isolation Relationship

Middle adulthood

(40-65 years)

Generativity vs stagnation Work and parenthood

Maturity

(65- death)

Ego integrity vs despair Reflection on life

7. Family History

Patient is the second child of 4 siblings.

No psychiatry history in the family.

GENOGRAM

8. Current Living Situation

He lives with his parents

E. Progressing of Illness

F. Level of Validity

Alloanamnesis : valid

Autoanamnesis : valid

II. Mental State

Examined on 30th Sept 2013

A. General Description

1. Apperance : a men, approriate to his age, wears complete clothes.

2. Conciousness : clear

3. Speech :

Quality : decreased

Quantity : decreased

4. Behaviour :

a. Hypoactive

b. Hyperactive

c. Echopraxia

d. Catatonia

e. Active negativism

f. Cataplexy

g. Streotypy

h. Mannerism

i. Automatism

j. Bizarre

5. Attitude :

a. Cooperative

b. Non-cooperative

c. Indiferrent

d. Apathy

e. Tension

f. Dependent

g. Active

k. Command automatism

l. Mutism

m. Acathysia

n. Tic

o. Somnabulism

p. Psychomotor agitation

q. Compulsive

r. Ataxia

s. Mimicry

t. Aggresive

u. Impulsive

i. Infantile

j. Distrust

k. Labile

l. Rigid

m. Passive negativism

n. Stereotypy

o. Catalepsy

p. Cerea flexibility

q. Excitement

h. Passive

6. Physic Contact :

Easily drawn, easily focused

Easily drawn, hardly focused

Hardly drawn, hardly focused

B. Emotion

1. Affect :

a. Appropriate

b. Inappropriate

c. Restrictive

d. Blunted

e. Flat

f. Labile

2. Mood :

a. Dysphoric

b. Euthymic

c. Elevated

d. Euphoria

e. Expansive

f. Irritable

g. Agitation

h. Can’t be assesed

C. Perception

1. Hallucination :

a. Auditory (+)

b. Visual

c. Olfactory

d. Gustatory

e. Tactile

2. Illusion :

a. Auditory (+)

b. Visual

c. Olfactory

d. Gustatory

e. Tactile

Depersonalize (-)

Derealisation (-)

D. Thought Process

1. Thought Progression

Quality :

a. Irrelevan answer

b. Incoherence

c. Flight of idea

d. Over-valued idea

e. Confabulation

f. Poverty of speech

g. Loosening of association

h. Neologisme

Quantity

a. Logorrhea

b. Blocking

c. Remming

2. Thought Content

i. Circumtansiality

j. Tangential

k. Verbigrasi

l. Perseverasi

m. Sound association

n. Word salad

o. Echolalia

d. Mutisme

e. Talk active

a. Preoccupation

b. Obsession

c. Phobia

d. Delusion of Persecution

e. Delusion of Reference

f. Delusion of Envious

g. Delusion of Hipochondry

h. Delusion of magic-mystic

3. Form of Thought

a. Realistic

b. Non Realistic

c. Dereistic

d. Autistic

E. Sensorium and Cognitive

1. Level of education : poor

2. General knowledge : poor

3. Orientation of time/place/people/situation: good/good/good/good

4. Working/short/long memory : enough

5. Writing and reading skills : enough

6. Visuospatial : not checked

7. Abstract thinking : enough

8. Ability to self care : enough

F. Impuls Control

1. Self control : good

2. Patient response to examiners question : enough

G. Insight

i. Delusion of grandiose

j. Delusion of Control

k. Delusion of Influence

l. Delusion of Passivity

m. Delusion of Perception

1. Impaired insight

2. Intelectual Insight

3. True Insight

III. Physical Examination

1. Internal State

Conciousness : Compos mentis

Vital sign :

Blood pressure : 130/90mmHg

Pulse rate : 120 x/mnt

Temperature : Afebris

RR : 20 x/mnt

Head : Normocephali Eyes : Anemic conjungtiva -/-, icteric sclera -/-, pupil isocore Neck : Normal, no rigidity, no palpable lymph nodes Thorax :

Cor : S 1,2 Sound and normal Lung : Vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound Extremity : Warm acral, capp refill <2”

2. Neurology : not checked

IV. Resume

A 34 years old male has been brought by his uncle because he was grumpy, open

offended, angry without reason, wandering alone, sleep disorder, giggle and talk by

himself and decreased appetite.

Mental State :

Conciiusness : clear

Behaviour : Impulsive

Attitude : Tension

Affect : Inapproriate

Mood : Irritable

Hallucination : Auditoric

Thought Progression : Flight of ideas; Talk active

Thouht Content : (-)

Insight : Impaired

V. Diffrerential Diagnosis

1. F20.2 Catatonic Schizophrenia

2. F25.0 Schizoafecttive Manic Type

3. F32.3 Severe Depressive episode with psychotic symptoms

VI. Multiaxial Diagnosis

Axis I : F20.5 Catatonic Schizophrenia

Z63.0 relationship problem with partner

Axis II : R46.8 delayed diagnosis of axis II

Axis III : No diagnose

Axis IV : Separated from his wife

Axis V : GAF admission 50-41

VII. Planning Management

1. Hospitalization

a. Hospital treatment plans should be oriented to secure patient’s safety.

b. The purpose of hospitalization is to decrease the symptoms, so patient can

handle herself and is not a threat to herself anymore.

c. Hospital treatment plans should be oriented toward practical issues of quality

of life, role function and social relationships.

d. To establish an effective association between patients and community support

systems.

2. Pharmacotherapy

Emergency therapy

Inj Haloperidol 5mg IM

Inj Diazepam 10mg IV

Routine therapy

Typical antipsychotic : Haloperidol 2 x 5 mg

3. Psycho-education

a. Explain to the family about probablity of mental disorder’s recurrence. That he

was admitted to RSJS (8 years ago), can be recyrrence, especially if there are

stressors, such as separated from his wife, economic problem.

b. Educate the patient and family : Patient need special attention and empathy, but

family need to avoid overreacting such as, too many critics on patient, too

indulgent and too controlling can complicate healing.

c. It is important to family to learn all they can about patient disorder to

understand the difficulties and problems associated with conditions.

d. It is also beneficial for family member to learn how to minimize the chance of

relapses, like familyh intervention can help the whole family develop behavior

patterns that promotes understanding and support for patient.

e. Patient need to understands that he has to keep take the medication for life, to

reduces his symptoms and avoid the risk of relapses

f. Patient need to understand that he need to control to physicians to follow up

about his condition.

VIII. Prognosis

Good Bad

History of mental illness in family (-)

Marital Status Married

Family Support (+)

Economic Status Intermediate

Stressors (+)

Premorbid personality Good

Illness progression Kronik

Illness Type Scyzho

23 years old

Treatment respond Good

Drugs compliance Not compliance

Conclusion :

Ad vitam : Bonam

Ad functionam : Dubia ad malam

Ad Sanatcanam : dubia ad malam