SUPERVISOR : dr. Sabar P. Siregar Sp.

KJ

 Name : Mrs. S
Age
: 49 Years Old
Gender
: Female
Address
: Ambarawa
Occupation
: Unemployed
Marriage Status
: Married
Religion
: Moslem
Last Education: Elementary High

School

 Name
: Mr. M
Age
: 52 Years Old
Gender
: Male
Relationship : Patients

Husband

 Patient

get amok, rude with others

and hit herself with her hands.

10 years ago
Raged to others
Injured herself
Forgot her family members
Cooped up
Patient rarely to talk to her neighbor

talk to her family.

Had good self grooming.

but still bit

Her sister-in-law died, she is not coming to her sister-in-law

funeral and she felt guilty because she didnt come to the
funeral.
Easily to get angry
Wont talk to others, even to her family.
Threaten her family member that she will hurt them.
Felt being followed by police because she is not coming to
her sister-in-law funeral.
Felt suspicious to her neighbor because she think that her
neighbor mock her.
Spoke and laugh to herself.
Easily to irritate

 10

years ago Patient hospitalized

in RSJS Magelang for 10 days.

Organic disease : (-)

Head injury
: (-)
Convulsion
: (-)

 Alcohol consumption
Tobacco consumption
Illicit drug use : (-)

: (-)
: (-)

 The patient married and had 4 children.

There is no information about family

history of mental disorder

Prenatal & perinatal : no data

Early childhood phase (0-3years old) : no data
Intermediate childhood (3-11 y.o)
: no data
Late childhood & teenage phase (11-18 y.o) : no data

Educational history

Occopational history

no data

Current situation

No data

Social activity

Married and had 4 children

Legal history

as a farmer at Ambarawa for several years, she was retired because her mental
condition.

Marriage status

Elementary high school

Lives with her husband, 3rd daughter and her husband and their 1 children.

Religion history

Moslem.

 Economy

scale : moderate-low

Alloanamnesis : Validity is certain

Autoanamnesis
: validity is
uncertain

201
0

unkno
wn

201
2

now

Appearance
Female, appropriate according to age, short

straight black hair, moderate self care, wearing

grey shirt and black trousers.

Level of consciousness
Clear

Speech
Quantity
Quality

: low
: enough

Mood
Euthymic
Dysphoric
Euphoria
Elevated
Expansive
Irritable

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Hallucination

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

Depersonalization (-)

Illusion

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

Derealization (-)

Idea of reference
Hypochondriac
Preoccupation
Obsession
Phobia
Delusion of magic
mystic
Delusion of infidelity
Delusion of control
Delusion of influence

 Realistic
Non realistic
Dereistic
Autistic

o
o
o
o
o
o
o
o
o
o

Level of education : Poor

General knowledge
: Cant be assesed
Orientation of time : Poor
Orientation of place
: Poor
Orientation of people
: Poor
Working/short/long memory
: Cant be assesed
Writing and reading skills
: Cant be assesed
Visuospatial : Cant be assesed
Abstract thinking : Cant be assesed
Ability to self care : Enough

 Impulse

control

Self control during assessment : enough

Patient response to examiner question
:

poor

Insight
Impaired insight
Intelectual insight
True insight

 General state
Conciousness
Vital sign:

: moderate sickness
: compos mentis

Blood pressure : 130/78 mmHg

Pulse rate
: 90x/mnt
Temperature
: 36.8C
RR:
: 28x/mnt

Head
: normocephali
Eyes anemic conjungtiva -/-, icterik sclera -/-, pupil
isocore
Neck : normal, no rigidity, no palpable lymphnode
Thorax:

Cor
: S1 and S2 sound clear and normal , reguler,
murmur - , gallop
Lung
: vesicullar sound, wheezing -, crackles -

Abdomen : Pain - , peristaltic normal, thympany

sound,

 Motoric

: normotonic, good
coordination of movement.
Physiological reflex : +/+
Pathological reflex : -/-

 No

data

Woman
48 y.o
Unemployed
Amok, Raged, injured herself, cooped up, lost of
appetite, easily to irritate, Spoke and laugh to
herself.
Always suspicious to her neighbor, feel being
followed by cops.
Affect : appropriate
Mood
: disforic
Halucination : auditory

F
F

20.0 paranoid schizophrenia

23.1 psychotic polymorphic acute
disorder with schizophrenia symptoms

 Axis

1 : F 20.0 Paranoid
Schizophrenia
Axis 2 : delayed
Axis 3 : delayed
Axis 4 : family-problem related
Axis 5 : GAF 40-31

 Medication
Diazepam 1 amp (i.v)
Lodomer 1 amp (i.m)

hospitalized

 Explain to patients family about his mental

disorder, describes steps of treatments

Describe stage of treatment
Explain the importance of support from family
and how the family members give care to the
patient
Explain to the patients family that they
shouldnt force patient to think like a normal
person.