F.16.

xx Mental and Behaviour

Disorder due to Hallucinogen
Used with???

Anisha Fazlisia P1536

Muhamad Fakhri P1538
 I. IDENTITY OF PATIENT
Name / Age : Mr. RH / 22 years old
MR : 898783
Gender : Male
Marital status : Single
Religion : Muslim
Occupation / School : Unemployment / Junior
High School
Citizen : Indonesian
Tribe : Minangkabau
Address :
III. Internal Status

General appearance :
Composmentis
Blood pressure : 110/80 mmHg
Pulse : palpable, regular,
84 times per minute,
Respiration :
abdominothoracal, regular,
20 times per minute
Temperature : 36,80C
Respiratory system
Inspection : Symmetrical on both left
and right site in static and
dynamic state
Palpation : Fremitus left side equal to the
right side
Percussion : Sonor throughout the lung
fields
Auscultation : Vesicular breath sounds, no
rhonchi, and no wheezing
Cardiovascular system :

Inspection :Ictus was not visible

Palpation :Ictus was palpable 1 finger at
the medial side of 5th RIC
LMCS
Percussion :Cardiac border was obtained
normal
Auscultation : Pure heart sounds, regular
rhythm, frequency 84x /
min, no cardiac murmur
Gastrointestinal system

Inspection :No Bulge

Palpation :Liver and spleen were not
palpable
Percussion : Tympanic
Auscultation : Normal intestinal murmurs
IV. NEUROLOGICAL STATUS
Central nervous System (sensory) :
sight, smell, hearing, taste, and touch were
fine

Symptoms of brain meningean stimulation:

necks stiffness negative

Symptoms of increase intracranial pressure :

projectile vomitting negative, progressive
headache negative
Eyes

Movement : can be moved in any

direction, nistagmus negative
Perception : diplopia negative
Pupil : round, isochors 3mm/3mm Lights
reflex : positive / positive
Convergence reflex : was not performed
Cornea reflex : was not performed
Ophthalmology : was not performed
Motoric
Tone : Eutone
Turgor : good
Strength : 555 555
555 555
Coordination: Good

Reflex
Physiologic (patella) : ++/++
(Achilles) : ++/++
Pathologic : Babinsky reflex negative
 Sensibility
Smooth and rough were good

Vegetative neuron
Eating, sleeping, and waking function were
normal

Supreme functions
Activity of reading, languange, writing,
drawing, and numeracy can be performed well
Spesific disorder
stiffness : none
tremor : none
nasal stiffness : none
occulogiric crisis : none
torticolis : none
VI. Multiple Axis Resume
Axis 1. Clinical Syndrome
Chief complaint was he lost his spirit to do daily activity
since 1 year ago.

General appearance:
Composmentis cooperative
sensorial was fine,
attention is good,
initiative is good,
motoric active,
facial expression was fair,
verbalization fluent,
psychic contact could be done, appropriate, and long

Specific condition

Affective condition :
Fair, unstable, little, echt, adequate, deep,
wide, fast

Intellectual condition and function:

Memorization ability good,
No difficulty in concentrating, orientation was
not disturbed, knowledge was good
Discriminative insight and judgement were
not disturbed
Intelligence prediction was average
Axis II. Personality Disorder and mental
retardation disorder
Personality : none
Mental retardation : none

Axis III. General medical condition

History of Head Injury

Axis IV. Phsycosocial and environtment

stressor
None
Axis V. Global assesment of function
Social relationship could be implemented
Free time activity could be done well.
Daily activity implemented.
Multiple Axis Diagnose

I. F.16.xx Mental and Behaviour

Disorder due to Hallucinogen Used
with???
II. No Diagnose
III. History of Head Injury
IV. No Diagnose
V. GAF 90-81
Differential Diagnose
F19. Mental and behavioral disorders
due to multiple substance and other
psychoactive substances use.
F32.0 Episode Depressive Ringan
Therapy
Pharmacotherapy
Fluoxetin 1x1tablet @ 20 mg
Risperidon 2x1 tablet @ 1 mg
Merlopam 1X1 tablet @ 0.5 mg (night use)
B complex 2x1 tablet

Psycotherapy
PROGNOSE
Clinical : dubia et bonam
Functional : dubia et bonam
Social : dubia et bonam