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 didnt 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.
Patiences 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 contact

: 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 capitiss 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 didnt 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 support 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