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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.