Case 1c4u1h

Private History 1. Prenatal/ Perinatal period Patient was born atterm and normal weight. The pregnancy was helped by midwife and cried spontaneously. 2. Early pediatric period (0-3 years) Patient grew and developed healthy like others. 3. Middle pediatric period (3-11 years) Patient has a big ego and feel that he didn’t get the same affection from is parent. Patient attend “silat tarikat” at 7 years old 4. Late pediatric period and adolescence period Patient lived seperatedly with his mom after the divorce. He live with his father in Java but lack of parental and decide to live alone. Patient sailing with his school group to continue his life

Private History 5. Adult period a. Education history 　　　 ES : 7 years, bad achievment when his parents divorce 　　　 JHS : 3 years, ordinary achievment 　　　 SHS : 3 years, ordinary achievment b. Job history: At 2009 sailing until 2011 and at 2014 employee of refill drinking water c. Marriage history: Single d. Religion history: The patient is Moeslim. He pray sometimes. e. Psychosexual history: There is no history of psychosexual history. f. Social activity: The patient and neighbor had no conflict. g. Violation of law history: There is no history of violation of law

Family History of Illnes

Graphic of illness

Recent life situation The patient lives with her mom in the house. Their communication is good. Patience’s perception and hope The patience hope can meet with his mom at hom immediately

General Condition Awareness Attitude Attention Inisiative Motoric behaviour Facial expression Speech and verbal Physical

: Composmentis : cooperative : present : present : active : rich : can speak, fluently and clearly : can be done, active, and less proper

Natural State of Feeling 1. Afective condition : euthym 2. Emotion Living: a. Stability 　 b. Control 　 c. ech – unecht d. einfuhlung ( invoelaarhaid ) e. deep-shallow f. differentiation scale g. emotion flow

: unstable : weak : echt : inadequate : shallow : narrow : fast

Intelectual Function Memory (amnesia) Concentration Orientation general knowledge discriminative insight alleged level of intelegency discriminative judgment intelectual deterioration

: good : good : good : good : not good, insight 1 : good : good : absent

Perseption and sensation anomaly a. illution : absent b.halutination - acustic : got, since 2011 - visual : got, since 2011 - olfatorik : absent - tactil : absent 　　 - gustatorik : absent

Way of Thinking 1. Psikomobility : fast 2. Thinking process a. clear and sharp : unclear and unsharp b. Sirkumstansial : present c. Inkoherrent : present d. Sperrung : absent e. Hemmung : absent f. Flight of ideas : absent g. Verbigerasi Persevarative : absent

3. Contents a. Central pattern : absent b. Phobia : absent c. Obsess : absent d. Dellusion : present e. Suspicion : present f. Confabulation : absent g. Animosity/revenge : absent h. Inferior feeling : positive i. Much/less : much j. Guilty feeling : absent k. Hippochondria : absent

E. Instinctual impulse disorders Abulia : absent Stupor : absent Raptus / impulsivitas : absent excitement state : absent sexual deviation : absent Echophraxia : absent Vagabondage : absent Piromani : absent Mannerisme : absent F. Overt anxiety G. Relation to reality

: positive, less : disturbed(mind,feel, behaviour)

Multiaxial Evaluation Axis I. Clinical Syndrome Specific condition : patient present angry until hit his mom and broke home aplliances 1. Natural State of Feeling : euthym, unstable, weak , echt, inadequate, shallow and, fast. 2. Intelectual function : memorizing abililty good, concentration ability adequate, orientation not disturbed in time, general knowledge good, discriminative insight distrub, allegged level of intelegency good, discriminative judgment distrub, intellectual deterioration absent. 3. Sensation and perception disorder: illusion absent, there are visual and acoustic halucination 4. Process of Thinking: fast, unclear and unsharp, circumstancial, incoherrent, delucion, suspicious and feeling inferior present 5. lInstinctual encouragement: abulia, stupor, raptus, excitement state, sexual deviation, echophraxia, vagabondage, pyromania, and mannerisme are absent. 6. Anxiety: positive, little 7. Relation to reality: disturbed (mind,feel, behaviour)

Multiaxial Evaluation Axis II : Personality Disorder and Mental Retardation Disorders 　　　　 Personality : extrovert 　　　　 Mental retardation : none Axis III : General Medical Condition • Trauma capitis’s history was not present • No history of malaria, typhoid, or brain and neurological disease • There is consumption alcohol and cigarette

Multiaxial Evaluation Axis IV : Phsychosocial Stressor and Environment Patient is a child of broken home, feel didn’t get the same love from his parents compare to his sibling. Axis V: Global Assessment of Function Moderate symptom and moderate disability

MULTIPLE AXIS DIAGNOSIS I. F.20.0 Schizophrenia paranoid II.No Diagnosis III.No Diagnosis IV.Problem with “primary group” V.GAF 60 - 51

DIFFERENTIAL DIAGNOSIS 1.F25.0 Schizoaffective manic type 2.F Bipolar affective disorder manic episode with psychotic symptoms

THERAPY Risperidon 2x2 mg Merlopam 1x1 mg Triheksiphenidyl 2 x 2 mg

PROGNOSIS Quo ad vitam Quo ad fungsionam Quo ad sanactionam

: bonam : bonam : dubia at bonam