Professional Documents
Culture Documents
1. Name : Mr. S
2. Age : 30 years old
3. Sex : male
4. Address : Batang
5. Job : Unemployed
6. Marital status : Single
7. Ethnicity : Javanese
8. Educational status : Elementary
Family Identity
1. Name : Mr. A
2. Age : 34 years old
3. Sex : male
4. Address : Batang
5. Job : Employee
6. Marital status : Married
7. Ethnicity : Javanese
8. Educational status : S1
Reason brought to hospital
2014
Patient start to get angry easily and irritable
Patient start to hear voices in his ear and see a ghost
Patient often wander
Patient still able to do ADL
Patient was hospitalized in RSJ Semarang
Progression of Disease
2015
Patient get angry easily, rage often, wander and talk to himself
Patient still can do ADL
4 days ago
Patient feels hard to sleep
Often daydreaming
Easily offended
Easily angry
Talk to himself
Seeing ghost
1 day ago
Patient hit his mother
Day of Admission
Patient was brought by his brother because his brother afraid the
patient can put others in danger
Patient will eat and take a bath only if told to do so
History of Past Illness
Psychiatric Illness
Hospitalized 1 year ago with the same symptom (11 days, patient get
better, didnt control to hospital)
General Illness
Patient has a few episodes of convulsion during infancy (his parent
didnt check to a doctor)
Patient has a retarded mental, known since elementary
Substance Abuse
Patient dont smoke, use drugs or drinks alcohol
Family History
There is no similar illness in the family
Physical Examination
Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S1 S2 regular, murmur -, gallop
Lung : vesicular sound +/+, wheezing -/-, ronchi-/-
Abdomen :
flat, abdominal wall//chest wall, normal peristaltic, tympany sound,
tenderness -, mass -, liver, spleen and kidney not papable
Extremity : Warm acral, capp refill <2, edema (-), tremor +
Cranial nerves examination:
CN I : not assessed
CN II : not assessed
CN III,IV,VI : not assessed
CN V : not assessed
CN VII : not assessed
CN VIII : not assessed
CN IX : not assessed
CN X : not assessed
CN XI : not assessed
CN XII : not assessed
Physiological reflex
Upper extremities: not assessed
Lower extremities: not assessed
Pathological reflex
Upper extremities: not assessed
Lower extremities: not assessed
Meningeal sign
not assessed
Cerebellum function
not assessed
Mental State Examination
General appearance
A male, age 30 years old, appropriate to her age, and wearing good cloth, self
grooming enough
Consciousness
Clear
Orientation
Time : good
People : good
Place : good
Situation : good
Behavior
Hypoactive Mutism
Tremor
Hyperactive Acathysia
Floxilation
Echopraxia Tic
Loss of energy
Catatonia Somnabulism
Dischynesia
Negativism Psychomotor agitation
Muscle rigidity
Cataplexy Compulsive
Bradychynesia
Stereotipy Ataxia
Khorea
Mannerism Mimicry
Convulsion
Automatism Aggresive
Dystonia
Command automatism Impulsive
Aminia
Bizarre Abulia
Attitude
Infantile
Cooperative
Distrust
Non-cooperative
Labil
Indiferrent
Rigid
Apathy
Passive negativism
Tension
Stereotipy
Dependent
Catalepsy
Passive
Cerea flexibility
Active
Excited
Mood
Mood:
Euthymic Affect:
Elevated Inappropriate
Dysphoric Restrictive
Euphoria Blunted
Expansive Flat
Irritable Labile
Thought of perception
Halusinasi Ilusi
Auditory (+) Auditory (-)
Olfactory (-) Visual (-)
Visual (+) Olfactory (-)
Gustatory (-) Gustatory (-)
Tactile (-) Tactile (-)
Somatic (-) Somatic (-)
Undeferrentiated (-) Undiferrentiated (-)
Realistic
Non realistic
Dereistic
Autistic
Sensorium and cognitive
Insight
Impaired insight
Intellectual insight
True insight
A female 36 years,
Impairment of socialization
Schizophrenia
Delusion of control
syndrome
Auditoric hallucination
Visual hallucination
Hospitalization
Angry and rampage without any reason.
He can be a threat to the others
Emergency Department
Inj. Diazepam 10 mg IV
Evaluation for Mental Retardation
Remission phase
Target therapy :
100% remission of symptom
Inpatient management
Risperidone tab 2mg 2x1
Improving the patient quality of life :
Teach patient about her social & environment (interact with
her family, socialize with her neighbor or friends, find a hobby
to do on her spare time)
Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy
Recovery Phase
Continue the medication, control to psychiatrist for at least 1 year
after hospitalization
Rehabilitation :
- Help patient to socialize well with other
- Give social support
- Find a hobby
Family Education
Explain to the family that anyone could have mental disorders
Mental disorders are caused by multifactorial factor, not only by
genetic inheritance
Mental disorders mostly are affected by chemical imbalance in brain
Mental disorders can be controlled by medicines, so it is important to
take the medicines routinely
Treat patient like you treat any other people
Help patient if he should be helped
Dont push patient to understand the family, but his family that has to
understand him
Dont be too emotional to patient
Thank You