MINI CEX

PSICOTIC

Oleh :
Mirantika Audina I4061172033

Pembimbing:
dr. Sabar Parluhutan Siregar, Sp.KJ

FAKULTAS KEDOKTERAN
UNIVERSITAS TANJUNGPURA
2018
IDENTITY

Patient’s Identity Relative Identity

• Name : Mr. M • Name : Mr. L
• Age : 45 years old • Age : 73 years old
• Gender : Male • Gender : Male
• Address : Magelang • Address : Magelang
• Religion : Moeslem • Occupational : Farmer
• Ethnic : Javanese • Relation : Biological Father
• Marital Status : Unmarried • Intimacy : Close
• Occupational : -
• Education : -
• Date of Entry : October 14ht,
2018
• Date of examination :
October 14ht, 2018
ANAMNESIS

The reason why patient was bring to the hospital

Patient bring to hospital because of bizzare behaviour

ANAMNESIS
Present story of patient illness :

• Alloanamnesis
From alloanamnesis with his father found that patient was
bring to mentol hospital Prof. dr. Soerojo Magelang
because of bizzare behaviour such as suddenly came to his
father, gave him back hug, kissed his neck and cheek, hold
his vital organ and asked him to have sex with him. Patient
started to forget his father since 2 months ago. His father
also said that he like to talk with their pet at home such as
birds and fishes. Since 4 month ago, he started to easily get
annoyed and angry, had difficulty in sleeping and said that
he ever met an acctrees. Her father also said that he ever
brought one of his neighbour to police station and stated
that he was a terrorist.
ANAMNESIS
Present story of patient illness :

• Autoanamnesis
From autoanamnesis, patient said that he was healthy and
wasnot sick. He stated taht he can listen and understand
talked of an animal especially their pet at home (fishes and
birds). He also belief that people around him can read his
mind besause it was brodcasted out of his head.
Sometimes at home he heard some voices on his ear that
like to comment about him. Patient beliaef that when he
was around many people, there are many people was
talking about him and want to do bad things to him.
ANAMNESIS
History of Illness :
• Psychiatric disorder :
Patient ever admitted to mental hospital for 7 times with the same
reason and stop for medication for 4 months
• General medical illness disorder :
There was a history of fever seizure when patient at 4 years old,
menawhile there was no history for chronic illness or head trauma
• Substance abuse :
History of smoking (+), alcohol use (-), drug abuse (-)
ANAMNESIS
History of Personal Life :

• Prenatal and Perinatal

There is o valid data.
• Early Childhood Phase :
There is no valid data
• Intermediate Childhood Phase :
There is no valid data
• Late Childhood and Teenager Phase :
There is no valid data
ANAMNESIS
• Adulthood Phase
- Education : patient studied until Senior High School
- Occupational : patient does not working
- Marital staus : unmarried
- Criminal : patinet has no criminal record
- Social activity : there was no valid data about how often
he spend time to hang out in his social life but he never
go out to talk to his neighbour
- Psycosocial : Patient have a normal relationship with his
parent and sibling. There was no data about his
personality
- Current situaton : Patient lived with his parent.

Family History :
There is no history of same symptoms in his family
PEMERIKSAAN FISIK
Status Internus
KU : Baik TD : 160/85 mmHg RR : 20 x/menit
Kesan : Compos mentis HR : 138 x/menit T : 36,8OC

Kepala Normocephal

CA(-/-), SI (-/-), pupil reguler bulat isokor 3 mm/3 mm, refleks cahaya
Mata
(+/+)

Mulut Bibir sianosis (-), mukosa bibir kering (-), atrofi papil lidah (-)

Leher Bentuk simetris, ↑JVP (-), pembesaran KGB (-)

Statis, bentuk dada simetris, kelainan kulit (-). Dinamis, gerakan paru
Inspeksi simetris, tidak ada gerakan paru yang tertinggal, penggunaan
otot bantu pernapasan (-)

Paru Palpasi Fremitus taktil paru kanan = paru kiri, nyeri tekan (-)

Perkusi Sonor dikedua lapang paru

Suara napas dasar: vesikuler (+/+). Suara napas tambahan: wheezing (-
Auskultasi
/-), ronkhi (-/-)
PEMERIKSAAN FISIK
Status Internus
Jantung Inspeksi Iktus kordis tidak terlihat
Palpasi Iktus kordis tidak teraba
Perkusi Batas kanan jantung: SIC IV linea parasternal dextra
Pinggang jantung: SIC III linea parasternal sinistra
Batas kiri jantung: SIC V linea midclavicularis sinistra
Auskultasi S1/ S2 reguler, murmur (-), gallop (-)
Abdomen Inspeksi Distensi (-), sikatrik (-)
Auskultasi Bising usus (+) 6x/menit
Perkusi Timpani
Palpasi Supel (+), hepar dan lien tidak teraba, nyeri tekan (-),
massa tidak teraba
Ekstremitas Akral hangat, CRT <2”, edema (-/-)

Kesimpulan dalam batas normal

PEMERIKSAAN FISIK
Status Neurologis
Motorik : Tonus normal, koordinasi gerakan baik, eutrofi,
kekuatan motorik 5/5/5/5
Meningeal sign : negatif
Refleks fisiologis : +/+
Refleks patologis : -/-
Sensorik : Dalam batas normal

Kesimpulan dalam batas normal

MENTAL STATUS EXAMINATION
General Appearance :
A male, 45 years old, inappropriate to his age, bad for self care,
wear complete and clean clothes
Orientation (P/T/P/S) : Good
Psycis contact : Present, euitable, constant.
Behavior : Normoactive
Verbal :
- Quantity : normal
- Quality : normal
Mood : Eutimic
Affect : Appropriate, blunted
Perception :
- Hallucination (+) auditoric
- Illusion (+) visual
- Depersonalization (-)
- Derealization (-)
MENTAL STATUS EXAMINATION
Thouhgt of Process :
- Quality : Coheren
- Quantity : Remming
Thouht of Content :
Delusion of magic mistic
Idea of suspicion
Thought Form :
Non-realistic
Insight : Impaired insight
Attention Connection :
Attention ngood enough, unable to sustained concentration
MENTAL STATUS EXAMINATION
Sensorium and Cognitive :
- Level of education : enough
- General knowledge : moderate
- Orientation : moderate
- Woring/Short/Long memory : enough
- Ability to read and write : moderate
- Ability to independent : moderate
Impulsive control when examine :
- Self control : enough
- Patient respons : enough
DIAGNOSIS
Schizofrenia syndrome :
- Bizzare behavior
- Auditoric hallucination
- Visual illusion
- Delusion of magic/mistic
- Can’t sleep
Paranoid syndrome :
Idea of suspicion

DIAGNOSIS BANDING
F20.3 Undifferentiated Schizofrenia
F20.5 Recidual Schizofrenia
F20.0 Paranoid Schizofrenia
DIAGNOSIS MULTIAKSIAL
AKSIS I : F20.3 Undifferentiated Schizofrenia
AKSIS II : There is no diagnosis
AKSIS III : There is no diagnosis
AKSIS IV : Problem with psycosocial and other
environtment
AKSIS V : 50 – 41 currently
MANAGEMENT PLANNING
Patient need to hospitalized
In emergency room :
Lodomer 5 mg/12 hours IM
Diazepam 10 mg/12 hours IV
Maintenance therapy :
Clozapin 25 mg 1x1 P.O
Haloperidol 5 mg 2x1 P.O
Remission Phase :
Haloperidol 5 mg 2x1 P.O
Psycotheray :
- Behavior management
- The patient need family support
- Explain that environment, neightborhood, family situation
assocaited to the disorder.
PROGNOSIS
Quo ad vitam : Bonam
Quo ad functionam : Dubia ad bonam
Quo of sanactionam : Dubia ad malam
THANK YOU