Sunday, 24th November 2013 Supervisor : dr Sabar P Siregar Sp.

KJ

PATIENTS IDENTITY
PATIENT GUARDIAN

Name : Ms. W Age : 18 years old Gender : Female Address : Parangsari Occupation : Unemployed Marriage status: Single Last education: Senior High School Religion : Islam

Name Age Relation Name Age Relation Name Age Relation

: Mrs. M : 41 years old : Mother : Mr. J : 48 years old : Father : Ms. I : 21 years old : Sister

4 days ago
The day in patient

Wandering and confuse since 4 days ago Talking and laughing to her own self Disturbing her neighbour Difficult to sleep Gain appetite has very low self esteem Difficult to maintain her concentration lazy to go to work.

Still wandering and confuse She was crying all day long

She had graduated 10 months ago. She had a boyfriend at Jakarta, but her mother forbid the relationship between them. She got the job in Kalimantan as a chef. She been there for 5 months, and she told her mother that her friends are being mean to her. And then, she went back home and applied a job in Solo as a cashier in a department store. But the same things happened again. She said, her friends accused her of being crazy. Since then, she went back home, and start to talking to herself, wandering, confused, has very low self esteem, and lazy to go to work. She eats more than usual and has difficulties to sleep. She used to be lock in her room by herself. Her mother said, she often being sad and cry. She likes watching tv but often its hard for her to concentrate and understand the contain of the tv show.

Psychiatry history She have been hospitalized twice in Puriwaluyo Hospital in Juni and July for about 10 days each. Her mother brought her to another doctor in Kentingan, and had been advice to going to Soerojo Psychiatric Hospital Magelang.

General medical history Febrile Seizure (-) Epilepsy (-) Trauma (-)

Drugs and alcohol abuse history and smoking history Alcohol consumption (-) Tobacco consumption (-) Drug abuse (-)

Her mother is 23 years old when she concieve the patient. She doesnt have history of illness during pregnant, the delivery is normal, aterm, assisted by traditional birth attendants.

Psychomotoric (NO VALID DATA) There were no valid data on patients growth and development such as:

first time lifting the head (3-6 months) rolling over (3-6 months) Sitting (6-9 months) Crawling (6-9 months) Standing (6-9 months) walking-running (9-12 months) holding objects in her hand(3-6 months) putting everything in her mouth(3-6 months)

Psychosocial (NO VALID DATA) There were no valid data on which age patient

started smiling when seeing another face (3-6 months) startled by noises(3-6 months) when the patient first laugh or squirm when asked to play, nor playing claps with others (6-9 months)
Communication (NO VALID DATA) There were no valid data on when patient started saying words 1 year like mamak or bapak. (6-9 months), because her mother already forget the detail.

Emotion (NO VALID DATA)

There were no valid data of patients reaction when playing,

frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (NO VALID DATA)

There were no valid data on which age the patient can follow

objects, recognizing her mother, recognize her family members. There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders.

Psychomotor (NO VALID DATA)

No valid data on when patients first time climbing the tree or hide and seek, if patient

ever involved in any kind of sports.

Psychosocial (NO VALID DATA)

There were no valid data on patients gender identification, interaction with her

surroundings
There were no data on when patient first entered primary school, how well patient

handles seperation from parents, how well he plays with new friends on first day of school
Communication (NO VALID DATA)
There were no valid data regarding patients ability to make friends in school, and

how many friends patient have during his schooling period.

Emotional (NO VALID DATA)

There were no valid data

Cognitive (VALID DATA)

Patients grades in school is average to the other friends, and always pass the

final exam until senior high school.

Sexual development signs & activity (NO VALID DATA) No data on when patient experience menarche, hair on armpits or , etc Psychomotor (NO VALID DATA) No valid data. Psychosocial (VALID DATA) She is a very shy girl. While she was in Kalimatan for working as a chef, she told her mother that she didnt have a friend. She also said that, all of her friends treated her badly. And this happened again while she was working in Solo as cashier. Her mother said, she had a boyfriend 5 months ago, while the patient graduate from senior high school. But since the patient went to Kalimantan, she lost contact with him.

Emotional (VALID DATA) She has a difficulty to express her feeling to her family and friends and continue to silent. As long as her mother knew, patient never attempted to break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugs Communication (VALID DATA) Patient has a bad relationship with parents and other family, especially her mother and her sisters.

Stage Infancy (birth to 18 months) Early childhood (2-3 years) Preschool (3-5 years) School age (6-11 years) Adolescence (12-18 years)

Basic Conflict Trust vs mistrust Autonomy vs shame and doubt Initiative vs guilt Industry vs inferiority Identity vs role confusion

Important Events Feeding Toilet training Exploration School Social relationships

Young Adulthood (19-40 years)

Middle adulthood (40-65 years) Maturity (65- death)

Intimacy vs isolation
Generativity vs stagnation Ego integrity vs despair

Relationship
Work and parenthood Reflection on life

Conclusion: not clear data

HISTORY
FAMILY HISTORY

PSYCHOSEXUAL HISTORY

The 2nd child from 3 siblings She has 2 sisters No other member of her family having the same symptoms as her.

Patient psychosexual history is appropriate of her gender. She sure she is female, and she attracted to another gender.

Male Female Passed away

Patient

Socio-economic history
Economical scale : low

Validity
Alloanamnesis Autoanamnesis : valid : valid

Symptoms

June 2013 Role of function

July 2013

The Day in Patient

Mental State (Sunday, 24th November 2013)

Appearance : A girl, appropriate according to her age, wear complete clothes, good self grooming

State of Consciousness
Clear Speech: Quantity : increased Quality : decreased

BEHAVIOUR
Normoactive Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism

Automatism Bizarre Command automatism

Mutism Acathysia Tic Somnabulism

Psychomotor agitation Compulsive Ataxia Mimicry Aggressive Impulsive Abulia

ATTITUDE
Cooperative
Non-cooperative Indiferrent Active Passive Infantile Distrust Labile Rigid Passive negativism Catalepsy Cerea flexibility Excitement

Apathy Tension Dependent

EMOTION
Mood Affect Appropriate Inappropriate Restrictive Blunted Flat Labile

Dysphoric Euthymic Elevated Euphoria Expansive Irritable Sad Depressed Cant be assesed

Disturbance of perception
Hallucination Auditory (+) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Undeferrentiated (-) Depersonalisation (-) Illusion

Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Undeferrentiated (-)
Derealisation (-)

Thought Progression
Quantity

Quality
Irrelevan answer Incoherence Flight of idea Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality Tangential Verbigrasi Perseverasi Sound association Word salad Echolalia

Normal Logorrhea Blocking Remming Mutisme Talk active

Content of Thought

Idea of Reference Preocupation Obsession

Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Thought of Echo Thought Insertion/withdrawal

Phobia
Delusion of Persecution Delusion of Reference Delusion of Envious Delusion of Hipokondry

Thought Broadcasting

Delusion of magic-mystic

Thought process
Realistic Non Realistic Dereistic Autistic

Sensorium and Cognition

Level of education : enough General knowledge : undiferrentiated Orientation of time/place/people/situation: good /good/good/good Working/short/long memory: good Writing and reading skills : good Visuospatial : enough Abstract thinking : enough Ability to self care : decrease

Impulse control when examined

Self control : enough Patient response to examiners question: good

Insight
Impaired insight Intellectual Insight True Insight

Internal Status
Conciousnes
Vital sign:

: compos mentis
: 110/80 mmHg : 88 x/minute : afebris : 20 x/minute

Blood pressure Pulse rate Temperature RR

 Head Eyes Neck

: normocephali : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore : normal, no rigidity, no palpable lymph nodes

Thorax:
Cor Lung : S1,2 Sound and normal : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound Extremity : Warm acral, capp refill <2

Motoric : Normotones, good coordination of movement Meningeal sign : negative Physiologic reflect : +/+ Patologic reflect : -/-

Onset: 4 days ago Stressor : Her relationship with her boyfriend

Symptoms

Impairment

Mental Status

Wandering and confuse since 4 days ago Talking and laughing to her own self Disturbing her neighbour Difficult to sleep Gain appetite has very low self esteem
Difficult to maintain her concentration lazy to go to work.

Behaviour : Hypoactive Attitude : Cooperative, dependent Mood : irritable, sad, depressed

-Unemployed
-Social withdrawal

Affect : aproppriate
Thought progression : talkactive Form of thought :Non-realistic Disturbance of perception: auditoric hallucination

Insight : intellectual insight

Differential Diagnose
F32.3 Severe Depression with psychotic

symptoms F25.1 Schizoaffective-Depression type

Multiaxial Diagnosis
Axis I Axis II Axis III Axis IV Axis V : F32.3 Severe Depression with psychotic symptoms : F60.1 Schizoid Personality Disorder : No diagnosis : Problems with primary support group : GAF admission 30-21

Hospitalization Pharmacotherapy Psycho-education after medication

 Hospitalization
Purpose of hospitalization is to decrease the

aggressive symptoms, so patient can handle himself, and not threatening people around him. Hospital treatment plans should be oriented toward practical issues of quality of life, role function and social relationships. To establish an effective association between patients and community support systems.

Pharmacotherapy O Emergency Room: - Inj Diazepam IV - Inj Haloperidol 5mg IM

O Routine therapy - Risperidon 2 x 1 - Fluoxetine 1 x 20 mg

Psycho-education
Educate the patient and family after medication: Explain to patients family about mental disorder. There are many factors cause the symptoms, such as biomolecules imbalance in the brain, so we need various aspects for the treatment. Dont force the patient to understand the family instead vice versa. Treat the patient according to the familys ability, dont demand the patient more nor less. Help the patient when he needs it. Education of the family to encourage communication and understanding.

Thank you...