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Wednesday, 30th October 2013

Supervisor : dr Sabar P Siregar Sp.Kj

PATIENTS IDENTITY
PATIENT

Name
: Mrs. SW
Age
: 26 years old
Gender
: Female
Address
: seneng
03/01 banyurojo
mertoyudan magelang
Occupation : Unemployed
Marriage status: Single
Last education: Senior
high school

GUARDIAN

Name
Age
Relation

: Mr. S
: 72 years old
: Father

COMPLAINT
Chief Complaint

Patient suddenly faint

ADDITIONAL COMPLAINT

Felt difficulty to breath


Felt that everybody
talking about her
Felt that everybody hate
her
Sometimes becomes
angry
Difficult to sleep

PRESENTING ILLNESS

4 days
ago
Now

Speak for themself


Laugh for no reason

Agitated
Faint
Difficult to breath
Increasing of appetite

HISTORY OF PRESENT ILLNESS

Psychiatry history
In 2005, 2010,
2012, & august
2013 taken to
hospital because
she laugh for no
reason and
speak for
themself

General medical
history
None

Drugs and alcohol


abuse history and
smoking history
Alcohol
consumption (-)
Tobacco
consumption (-)
drug use (-)

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)


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 mom or dad. (6-9
months)

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

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)


Psychomotor (NO VALID DATA)

No valid data on when patients first time riding a tricycle or bicycle, if patient ever
involved in any kind of sports.

Psychosocial (NO VALID DATA)

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

No valid data on patients adaptation under stress

Cognitive (No VALID DATA)

No valid data on patients grades in school

LATE CHILDHOOD & TEENAGE PHASE


Sexual development signs & activity (NO VALID DATA)
No data on when patient experience sexual , hair on armpits, etc
Psychomotor (NO VALID DATA)
No data if patient had any favourite hobbies or games, if patient involved
in any kind of sports.
Psychosocial (NO VALID DATA)
No data if while growing up did he make many friends, how well patient
make any friends and how much friends.
No valid data on when and how patients relationship with different
gender, if patient ever had any relationship with the opposite gender.
Emotional (VALID DATA)
Patient seldom told friends or family regarding any problems.
No data if patient attempted to break the rules (truant schools subject,
fight with friends, bullying, etc) and consuming alcohol, smoke and
drugs
Communication (NO VALID DATA)
Patient has a goog relationship with parents and other family.

ADULTHOOD

Educational History
Senior High School

Occupational history
None

Marital Status
unmarried

Criminal History
None

Social Activity
Patient seldom to get interaction with her
neighbour

Current Situation
Lives with his parents

Religious history
Pray routinely before illness

ERIKSONS STAGES OF PSYCHOSOCIAL


DEVELOPMENT
Stage

Basic Conflict

Important Events

Infancy
(birth to 18 months)

Trust vs mistrust

Feeding

Early childhood
(2-3 years)

Autonomy vs shame and


doubt

Toilet training

Preschool
(3-5 years)

Initiative vs guilt

Exploration

School age
(6-11 years)

Industry vs inferiority

School

Adolescence
(12-18 years)

Identity vs role confusion

Social relationships

Young Adulthood
(19-40 years)

Intimacy vs isolation

Relationship

Middle adulthood
(40-65 years)

Generativity vs stagnation

Work and parenthood

Maturity
(65- death)

Ego integrity vs despair

Reflection on life

Conclusion: not clear data

HISTORY
Family History

The last child from 4


siblings
He has two brothers and
one sister

Psychosexual history

Patient psychosexual
history is appropriate
of his gender. He
realizes that he is
female and behaves
according to his
gender.

GENOGRAM

Socio-economic history
Economic scale

: low

Validity
Alloanamnesis
Autoanamnesis

: valid
: valid

PROGRESSION OF ILNESS
symptom

2005

Role function

2010

2012 Agustus now


2013

Mental State
(Wednesday, 30th October 2013)
Appearance :
a woman, appropriate according to age, wear
complete clothes, good self grooming

State of Consciousness
Clear
Speech:
Quantity : increased
Quality

: increased

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active
negativism
Cataplexy
Streotypy

Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic
Somnabulism

Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

ATTITUDE

Cooperative
Noncooperative
Indiferrent
Apathy
Tension
Dependent

Active
Passive
Infantile
Distrust
Labile
Rigid

Passive
negativism
Stereotypy
Catalepsy
Cerea
flexibility
Excitement

Emotion
Affect

Mood

Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Cant be assesed

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of perception

Hallucination

Auditory (+)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Undeferrentiated (-)
Depersonalisation (-)

Illusion

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

Thinking thought progression


Quantity

Normal
Logorrhea
Blocking
Remming
Mutisme
Talk active

Quality

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

Content of thought

Idea of Reference

Delusion of grandiose

Preocupation

Delusion of Control

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Delusion of Persecution

Delusion of Perception

Delusion of Reference

Delusion of suspicious

Delusion of Envious

Thought of Echo

Delusion of Hipokondry

Thought Insertion/withdrawal

Delusion of magic-mystic

Thought Broadcasting

Thought process
Realistic
Non Realistic
Dereistic
Autistic

Sensorium and Cognition

Level of education
: enough
General knowledge
: undeferrentiated
Orientation of time/place/people/situation:
good
Working/short/long memory: not checked
Writing and reading skills : not checked
Visuospatial
: not checked
Abstract thinking
: not checked
Ability to self care
: enough

Impulse control when examined


Self control : bad
Patient response to examiners question:
bad

Insight
Impaired insight
Intelectual Insight
True Insight

Internal Status
Conciousnes

: compos mentis

Vital sign:

Blood pressure
Pulse rate
Temperature
RR

: 140/80 mmHg
: 104 x/mnt
: afebris
: 24 x/mnt

Head

: normocephali

Eyes

: anemic conjungtiva -/-, icteric sclera -/-, pupil isocore

Neck

: normal, no rigidity, no palpable lymph nodes

Thorax:
Cor

: S1,2 Sound and normal

Lung

: vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound


Extremity : Warm acral, capp refill <2
VE on pedis sinistra

NEUROLOGICAL STATUS
Motorik :not checked
Meningeal sign : not checked
Patologic reflect : not checked
Physiologic reflect : not checked

SIGNIFICANT FINDING RESUME

Sym
ptom
s

Onset: 4 days ago


Stressor: Unknown

Disabili
ty

Anger tantrums, Agitated


and sensitive
Talk and laugh by herself

Hearing voices
Difficult to sleep
Felt everybody hate and
talking about her

Unemployed
- Socially
aggressive

Mental Status
Behaviour : Cataplexy,
Psychomotor agitation, Agitation
Attitude : Non cooperative
Mood : Irritable ; Affect :
Appropriate
Thought progression : talk
active, flight of idea
Form of thought : Non-realistic
Insight : true insight

Differential Diagnose
F20.0 Schizophrenia Paranoid
F20.4 Depression post Schizophrenia
F33.3 Disorder of repeated

depressive, severe episode with


pshycotic symptom

Multiaxial Diagnose
Axis I
Axis II
Axis III
Axis IV
Axis V

: F20.3 Undefferentiated schizophrenia


: R46.8 diagnosis axis II delay
: no diagnose
: Prymary support group problem
: GAF admission 20-11
GAF 1 year recent 20-11

PLANNING MANAGEMENT
Hospitalization
Fixaxion
Pharmacotherapy
Psycho-education after medication

PLANNING MANAGEMENT

Hospitalization
Purpose of hospitalization is to decrease the
aggressive symptoms, so patient can handle
himself, and no 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.

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

Routine therapy
- Antipsikotik tipikal
- Haloperidol 2 x 5mg

PLANNING MANAGEMENT
Psycho-education
Educate the patient and family :
Explain to patients family about mental disorder.
There are many factors cause the symptoms, such as
biommolecules 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.
Keep the patient away from objects that can harm
other people and patient.

Thank you