I.

Examination of Psychiatry History

Patients Identity Autoanamnesis Name Age Gender Address Occu a!ion Mari!al s!a!us #as! educa!ion : Mr. K : 34 years old : Male : Banyubiru, Purworejo : "armer : Married : $unior %ig& 'c&ool (gradua!ed)

Alloanamnesis Name Age +ela!ion : Mr. % : 4* years old : ,ncle

Psychiatry History : Au!oanamnesis and alloanamnesis was ob!ained on 3-!& 'e !ember .-/3 in 0mergency +oom a! .-:-- m, +'$ Pro1. 'oeroyo Magelang.

A.

Chief Complaint : Grum y

B.

History of Present Illness A ro2ima!ely . mon!&s ago, a!ien! was angry wi!&ou! reason, giggle and !al3 by &imsel1 and slee disorder. 4&e a!ien! &ad roblem in role 1unc!ion, bu! good in social rela!ion, good sel1 care, and good s are!ime managemen!.According !o a!ien!5s uncle, be1ore !&e onse! o1 c&ange abou! 3 mon!&s ago, a!ien! &ad se ara!ed 1rom &is wi1e ago because a!ien! su11erred a 1inancial loss and &is wi1e lea6e &im. 4&e a!ien! &ad as3ed &is wi1e !o be reconciled, bu! &is wi1e rejec!. One mon!& ago, !&e a!ien! &ad slee disorder (&ard !o ini!a!e slee ), wandering alone, angry wi!&ou! reason !o o!&er and s are!ime managemen!. 7ay o1 admission, !&e a!ien! was broug&! by &is uncle because &e was grum y, !oo easily o11ended and dis!urbing &is neig&bor&ood, &ad slee disorder (&ard !o ini!a!e slee ), wandering alone, low a e!i!e, giggle and !al3 by &imsel1. 4&e role 1unc!ion, social 1unc!ion, s are!ime managemen! and sel1 care was oor. 8&en &is uncle broug&! &im !o +'$' Magelang, &is uncle was lied !o &im, so !&e a!ien! became angry and go! berser3. eo le around &im, low a e!i!e, giggle and !al3 by &imsel1. 4&e a!ien! s!ill wor3ed as clo6e merc&an!, bu! &e was oor in role 1unc!ion

C.

Past Medical History /. Psyc&ia!ric %is!ory 9n .--: !&e a!ien! was admi!!ed !o +'$ 1or similar sym !oms. %e was ed. "rom .--= un!il .-/3 !&e

&os i!ali;a!ion 1or 3 mon!&s and go! some medicine 1rom !&e &os i!al. 4&e a!ien! &ad consume !&e medicine un!il .--< and &e s!o a!ien! did no! consumed any medicine and &e can do &is daily ac!i6y li3es normal.

.. General Medical %is!ory No serious &ysical &is!ory. %is!ory o1 sei;ure or &ead injury (!rauma) was denied.

3. %ys!ory o1 Alco&ol, 'mo3e and 7rug ,se Pa!ien! admi! !&a! &e smo3e cigare!!e since &e was /< years old.

D.

History of Personal Life /. Prena!al and Perina!al %is!ory Pa!ien! was born in Purworejo, .< Marc& /=*= e2 ec!ed bi!r&. No da!a on medical condi!ions and nu!ri!ions during !&e mo!&er5s regnancy.

.. 0arly >&il&ood P&ase ( - ?3 years old) a. Psychomotoric (NO VALID DATA) 4&ere were no 6alid da!a on a!ien!s grow!& and de6elo men! suc& as: "irs! !ime li1!ing !&e &ead (3?@ mon!&s) +olling o6er (3?@ mon!&s) 'i!!ing (@?= mon!&s) >rawling (@?= mon!&s) '!anding (@?= mon!&s) 8al3ing?running (=?/. mon!&s)

%olding objec!s in &er &and(3?@ mon!&s) Pu!!ing e6ery!&ing in &er mou!&(3?@ mon!&s)

b. Psychosocial (NO VALID DATA) 4&ere were no 6alid da!a on w&ic& age a!ien!. '!ar!ed smiling w&en seeing ano!&er 1ace (3?@ mon!&s) '!ar!led by noises(3?@ mon!&s) 8&en !&e a!ien! 1irs! laug& or sAuirm w&en as3ed !o lay, nor laying cla s wi!& o!&ers (@?= mon!&s) c. Communication (NO VALID DATA) 4&ere were no 6alid da!a on w&en a!ien! s!ar!ed saying words / year li3e Bmom5 or Bdad5. (@?= mon!&s) d. motion (NO VALID DATA) 4&ere were no 6alid da!a o1 a!ien!5s reac!ion w&en laying, 1rig&!ened by s!rangers, w&en s!ar!ing !o s&ow jealousy or com e!i!i6eness !owards o!&er and !oile! !raining. e. Co!niti"e (NO VALID DATA) 4&ere were no 6alid da!a on w&ic& age !&e a!ien! can 1ollow objec!s, recogni;ing &er mo!&er, recogni;e &er 1amily members. 4&ere were no 6alid da!a on w&en !&e a!ien! 1irs! co ied sounds !&a! were &eard, or unders!anding sim le orders.

3. 9n!ermedia!e >&ild&ood P&ase ( 3 C // yeras old) a. Psychomotor (NO VALID DATA)

No 6alid da!a on w&en a!ien!5s 1irs! !ime riding a !ricycle or bicycle, i1 a!ien! e6er in6ol6ed in any 3ind o1 s or!s b. Psychosocial (NO VALID DATA) No 6alid da!a on a!ien! in!erac!ion wi!& &is surrounding, no 6alid da!a on w&en sc&ool. c. Communication (NO VALID DATA) No 6alid da!a regarding a!ien! abili!y !o ma3e 1riends a! sc&ool and &ow many 1riends a!ien! &a6e during &is sc&ool eriod d. motional (NO VALID DATA) No 6alid da!a on a!ien!5s ada !a!ion under s!ress, any inciden!s o1 bedwe!!ing were no! 3nown. e. Co!niti"e (NO VALID DATA) No 6alid da!a on a!ien!5s cogni!i6e. a!ien! 1irs! en!ered rimary sc&ool, on &ow well a!ien! &andle se era!ion 1rom aren!, &ow well &e lay wi!& &is new 1riend on 1irs! day

4. #a!e >&ild&ood and 4eenage P&ase ( // C /< years old) a. #e$ual de"elo%ment si!ns & acti"ity (NO VALID DATA) No da!a on w&en a!ien! e2 erience we! dream, &air on arm i!s and ubis, e!c. b. Psychomotor (NO VALID DATA) No da!a i1 a!ien! &ad any 1a6ouri!e &obbies or games, i1 a!ien! in6ol6ed in any 3ind o1 s or!s. c. Psychosocial (NO VALID DATA)

Pa!ien! &ad ne6er been !old !&e aren! abou! a!ien! 1riend. d. motional (NO VALID DATA) No 6alid da!a on a!ien!s reac!ion on laying, scared, s&owed jealously or com e!i!i6eness. e. Communication (NO VALID DATA) No 6alid da!a on &ow well !&e rela!ions&i be!ween a!ien! wi!& aren! and o!&er 1amily.

:. Aldul!&ood %is!ory a. ducational 'istory unior &ig& sc&ool (gradua!ed) b. Occu%ational 'istory >lo6e merc&an! c. (arital #tatus Married in .--@, bu! se ara!ed 1rom &is wi1e. d. Criminal 'istory No e. #ocial Acti"ity Be1ore disorder was normal ). *eli!ious 'istory Pray no! rou!inely.

@. Psyc&ose2ual %is!ory Pa!ien! syc&ose2ual &is!ory is a ro ria!e o1 &is gender and a!!rac!ed !o woman.

Eri son!s sta"es of psychosocial de#elopment

$ta"e 9n1ancy (bir!& !o /< mon!&s) 0arly c&ild&ood (.?3 years) Presc&ool (3?: years) 'c&ool age (@?// years) Adolescence (/.?/< years) %oun" Adulthood &'()*+ years, Middle adul!&ood (4-?@: years) Ma!uri!y (@:? dea!&) *. "amily %is!ory

Basic Conflict 4rus! 6s mis!rus!

Important E#ents "eeding

Au!onomy 6s s&ame and doub!

4oile! !raining

9ni!ia!i6e 6s guil!

02 lora!ion

9ndus!ry 6s in1eriori!y

'c&ool

9den!i!y 6s role con1usion

'ocial rela!ions&i s

Intimacy #s isolation

-elationship

Genera!i6i!y 6s s!agna!ion

8or3 and aren!&ood

0go in!egri!y 6s des air

+e1lec!ion on li1e

Pa!ien! is !&e second c&ild o1 4 siblings. No syc&ia!ry &is!ory in !&e 1amily.

G0NOG+AM

<. >urren! #i6ing 'i!ua!ion %e li6es wi!& &is aren!s

E.

Pro"ressin" of Illness

..

Le#el of /alidity Alloanamnesis Au!oanamnesis : 6alid : 6alid

II.

Mental $tate
02amined on 3-!& 'e ! .-/3 A. 0eneral Description /. .. 3. A erance : a men, a roria!e !o &is age, wears com le!e clo!&es. : clear : : decreased : decreased

>onciousness ' eec& Duali!y Duan!i!y

4.

Be&a6iour a. %y oac!i6e b. %y erac!i6e c. 0c&o ra2ia d. >a!a!onia

: 3. >ommand au!oma!ism l. Mu!ism m. Aca!&ysia n. 4ic o. 'omnabulism . Psyc&omo!or agi!a!ion A. >om ulsi6e r. A!a2ia

e. Ac!i6e nega!i6ism 1. >a!a le2y g. '!reo!y y &. Mannerism i. Au!oma!ism j. Bi;arre

:.

A!!i!ude a. >oo era!i6e b. Non?coo era!i6e c. 9ndi1erren! d. A a!&y e. 1ension

: i. 9n1an!ile j. 7is!rus! 3. #abile l. +igid m. Passi6e nega!i6ism n. '!ereo!y y o. >a!ale sy

1. 7e enden! g. Ac!i6e &. Passi6e

@.

P&ysic >on!ac!

Easily dra2n3 easily focused 0asily drawn, &ardly 1ocused %ardly drawn, &ardly 1ocused

B. Emotion /. A11ec! :

a. A ro ria!e 4. Inappropriate c. +es!ric!i6e d. Blun!ed e. "la! 1. #abile

.. Mood

a. 7ys &oric

b. 0u!&ymic c. 0le6a!ed d. 0u &oria e. 02 ansi6e f. Irrita4le g. Agi!a!ion &. >an5! be assesed

C. Perception /. %allucina!ion a. Auditory &5, b. Eisual c. Ol1ac!ory d. Gus!a!ory e. 4ac!ile :

.. 9llusion a. Audi!ory (F) b. Eisual c. Ol1ac!ory d. Gus!a!ory

e. 4ac!ile

7e ersonali;e (?) 7erealisa!ion (?)

D. 1hou"ht Process /. 4&oug&! Progression Duali!y : i. >ircum!ansiali!y a. 9rrele6an answer j. 4angen!ial b. 9nco&erence 3. Eerbigrasi c. .li"ht of idea l. Perse6erasi d. O6er?6alued idea m. 'ound associa!ion e. >on1abula!ion n. 8ord salad 1. Po6er!y o1 s eec& g. #oosening o1 associa!ion &. Neologisme

Duan!i!y a. #ogorr&ea b. Bloc3ing c. +emming d. Mu!isme e. 1al acti#e

.. 4&oug&! >on!en! a. Preoccu a!ion b. Obsession c. P&obia d. 7elusion o1 Persecu!ion e. 7elusion o1 +e1erence 1. 7elusion o1 0n6ious g. 7elusion o1 %i oc&ondry &. 7elusion o1 magic?mys!ic i. 7elusion o1 grandiose j. 7elusion o1 >on!rol 3. 7elusion o1 9n1luence l. 7elusion o1 Passi6i!y m. 7elusion o1 Perce !ion

3. "orm o1 4&oug&! a. +ealis!ic b. Non +ealis!ic c. 7ereis!ic d. Autistic

E. $ensorium and Co"niti#e /. #e6el o1 educa!ion .. General 3nowledge : oor : oor

3. Orien!a!ion o1 !imeG laceG eo leGsi!ua!ion: goodGgoodGgoodGgood 4. 8or3ingGs&or!Glong memory : enoug&

:. 8ri!ing and reading s3ills @. Eisuos a!ial *. Abs!rac! !&in3ing <. Abili!y !o sel1 care

: enoug& : no! c&ec3ed : enoug& : enoug&

.. Impuls Control /. 'el1 con!rol .. Pa!ien! res onse !o e2aminers Aues!ion : good : enoug&

0. Insi"ht '. Impaired insi"ht .. 9n!elec!ual 9nsig&! 3. 4rue 9nsig&!

III.

Physical Examination
/. 9n!ernal '!a!e >onciousness Ei!al sign Blood ressure Pulse ra!e : >om os men!is : : /3-G=-mm%g : /.- 2Gmn!

4em era!ure ++ %ead 0yes Nec3 4&ora2 >or #ung

: A1ebris : .- 2Gmn! : Normoce &ali : Anemic conjung!i6a ?G?, ic!eric sclera ?G?, u il isocore : Normal, no rigidi!y, no al able lym & nodes : : ' /,. 'ound and normal : Eesicular sound, w&ee;ing ?G?, ronc&i?G? : Pain (?) , normal eris!al!ic, !ym any sound : 8arm acral, ca re1ill H.I

Abdomen 02!remi!y

.. Neurology

: no! c&ec3ed

I/.

-esume
A 34 years old male &as been broug&! by &is uncle because &e was grum y, o en o11ended, angry wi!&ou! reason, wandering alone, slee disorder, giggle and !al3 by &imsel1 and decreased a e!i!e. Men!al '!a!e : >onciiusness Be&a6iour A!!i!ude A11ec! : clear : 9m ulsi6e : 4ension : 9na roria!e

Mood %allucina!ion

: 9rri!able : Audi!oric : "lig&! o1 ideasJ 4al3 ac!i6e

4&oug&! Progression 4&ou&! >on!en! : (?) 9nsig&!

: 9m aired

/.

Diffrerential Dia"nosis
/. .. 3. ".-.. >a!a!onic 'c&i;o &renia ".:.- 'c&i;oa1ec!!i6e Manic 4y e "3..3 'e6ere 7e ressi6e e isode wi!& syc&o!ic sym !oms

/I.

Multiaxial Dia"nosis
A2is 9 : ".-.: >a!a!onic 'c&i;o &renia K@3.- rela!ions&i A2is 99 A2is 999 A2is 9E A2is E roblem wi!& ar!ner

: +4@.< delayed diagnosis o1 a2is 99 : No diagnose : 'e ara!ed 1rom &is wi1e : GA" admission :-?4/

/II. Plannin" Mana"ement

/. %os i!ali;a!ion

a. b.

%os i!al !rea!men! lans s&ould be orien!ed !o secure a!ien!5s sa1e!y. 4&e ur ose o1 &os i!ali;a!ion is !o decrease !&e sym !oms, so a!ien! can &andle &ersel1 and is no! a !&rea! !o &ersel1 anymore.

c.

%os i!al !rea!men! lans s&ould be orien!ed !oward rac!ical issues o1 Auali!y o1 li1e, role 1unc!ion and social rela!ions&i s.

d.

4o es!ablis& an e11ec!i6e associa!ion be!ween a!ien!s and communi!y su sys!ems.

or!

..

P&armaco!&era y 0mergency !&era y 9nj %alo eridol :mg 9M 9nj 7ia;e am /-mg 9E

+ou!ine !&era y 4y ical an!i syc&o!ic : %alo eridol . 2 : mg

3.

Psyc&o?educa!ion a. 02 lain !o !&e 1amily abou! robabli!y o1 men!al disorder5s recurrence. 4&a! &e was admi!!ed !o +'$' (< years ago), can be recyrrence, es ecially i1 !&ere are s!ressors, suc& as se ara!ed 1rom &is wi1e, economic roblem. b. 0duca!e !&e a!ien! and 1amily : Pa!ien! need s ecial a!!en!ion and em a!&y, bu! 1amily need !o a6oid o6erreac!ing suc& as, !oo many cri!ics on a!ien!, !oo indulgen! and !oo con!rolling can com lica!e &ealing.

c. 9! is im or!an! !o 1amily !o learn all !&ey can abou!

a!ien! disorder !o

unders!and !&e di11icul!ies and roblems associa!ed wi!& condi!ions. d. 9! is also bene1icial 1or 1amily member !o learn &ow !o minimi;e !&e c&ance o1 rela ses, li3e 1amily& in!er6en!ion can &el !&e w&ole 1amily de6elo be&a6ior a!!erns !&a! romo!es unders!anding and su or! 1or a!ien!.

e. Pa!ien! need !o unders!ands !&a! &e &as !o 3ee !a3e !&e medica!ion 1or li1e, !o reduces &is sym !oms and a6oid !&e ris3 o1 rela ses 1. Pa!ien! need !o unders!and !&a! &e need !o con!rol !o &ysicians !o 1ollow u abou! &is condi!ion.

/III. Pro"nosis
%is!ory o1 men!al illness in 1amily Mari!al '!a!us "amily 'u or! 0conomic '!a!us '!ressors Premorbid ersonali!y 9llness rogression 9llness 4y e .3 years old 4rea!men! res ond 7rugs com liance (?) Married (F) 9n!ermedia!e (F) Good Kroni3 'cy;&o Good No! com liance Good Bad

>onclusion Ad 6i!am

: : Bonam

Ad 1unc!ionam Ad 'ana!canam

: 7ubia ad malam : dubia ad malam