Post on 04-Apr-2018
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Group 3
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Name : Mr. A
Gender : Man
Age : 32 y.o
Religion : Moslem
Ethnic : Sunda
Latest education :Senior High school
Job : not working
Marriage status : Not yet
Address : Jalan Gang Masjid, jalan raya
Munjul, Cibubur
Hospitalized entry date : Nov 2nd 2012
Patient hospitalized accompanied by his mother
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An information is taken by autoanamnesis and
alloanamnesis from his mother in december 11th and
12th 2012
Chief complain
A patient came with his mother to RSKO, with chief
complain was got angry easily and frequently and
defeated another people since 3 months ago beforehospitalized
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Brought because
want to dorehabilitation
Reason : all his wantsdidnt give since
5months ago afterdidnt work and usedganja again 2 weekes
ago
Assumption his familydidnt care & love tohim because his
mother never allow himto married with thewoman which he
choosed
often went out with his friendand stayed at home rarely.
got angry easily and frequently, fought with other people if all
wants didnt give. Ever brought by his
neighbourhood to the policestation because made a trouble.
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1. Psychiatry History
Got medication from psychiatry doctor at Polri hospital when 1st
grade of SHS brought by his family because he often seen
depressed and laughed by himself when he alone got a
medication for 3 years. Sent to Marzuki Mahdi Hospital after heard whisper sounds
(never order him to hurt somebody else or did something that he
never want to do, just talked) and it disturbed him. Felt his body
inserted by a woman with long hair (till now) and saw
hallusination several times ( a woman )
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2. History of psycoactive drugs used
Putau since 2005
(1st grade of senior
high school)
According his
family
BK tablet (1st
grade of junior high
school till 3rd ) 2
tablets in one day.
According the
patient. He alsoconsumed alcohol
Ganja (3rd grade of
junior high school).
Consumed
everyday, 1 stick in
1 day
According the
patient, he used
putau at that year.
He used 1 syringe
pump together with
his friends. 1
syringe pump for 8
till 10 people.
got a medication from RSKOpost hospitalized at TNI hospital
1 year ago, patient didnt use
putau or other drugs anymore.
According laboratory
examination result, showed he
didnt use it, it was negative.
Used
again 2weeks
before
rehabilitat
ion
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3. History of medical illness
Ever seizure and unconciousness 1 year ago, got dhiarre also brought toRSKO but there wasnt any ICU room there sent to Pasar Rebo hospital,
patient got a treatment at IGD room for 3days (better condition) sent to TNI
hospital because the ICU room at Pasar Rebo hospital was fully.
Did VCT at TNI hospital (doctor saw a tatoo in both his arms and the trackneedles) HIV positive CD4 459 Hospitalized for 1 week
unconciousness because his HIV ( TE ) sent to RSKO to did intensive
treatment.
The latest medication (RSKO)
did urin examination 3 times (all werenegative)
5 months ago did a laboratory examination again CD4 411
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Prenatal and perinatal
Patient is a second children from 3 siblings. He was born normally, 9 months.
Helped by midwife, cried directly, born weight 4200 gr
Beginning of childhood life (0-3 y.o)
He grew up as well. An immunization didnt complete. Patient lives with his
family.
Middle of childhood life ( 3-11 y.o)
He had lots of friend. He also got an achivement when he was at elementary
school. Patient went out rarely. After school, he stayed at home and took a nap.
Patient just went out, played with his friends didnt far from his house and came
back before magrib.
The end of childhood and adolesence life
Hes a socialized typical person who most of the time waste with his friends. He
often invited by his friends to used alcohol and other drugs. He was being
dependence and gathered along with his friends became his habit till adult. Since
that, patient often went out when night came, his education was ruined esp when
he was at 2nd grade of junior high school.
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Adulthood life
1. Education history
Didnt continue a next grade when he was at 2nd grade of junior high school. Moved to
boarding school and didnt finish it when he was seniorhigj school
2. Work History
Patient ever worked for 3 weeks at bekasibut got a fired from his job. He didnt know
what the reason, he only knew that not only him who got a fired but others also
3.
Marriage historyNot yet
4. Religion History
Moslem
5. Psycosexual History
He attracted by a woman when he was adolesence, had a relationship 1 time when senior
high school and had a wanted to married her but his family didnt allow him
6. Social activity
He prefer socialized with friends who introduced him with alcohol and drugs and almost
never followed religion and other social activities
7. History of law infraction
Patient ever caught by police because made a mess
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Patient feel his life is better than before. Headmit that he cant interact with otherpatient easily, just several which close withhim.
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= Patient
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Pasien always think that himself is a kind
person, dont have a grudge easily, socializedand share with others happily
Patient want to get married like his sister andbrother, want to have one small happy family.He also want to get a job due to help hisparent.