Monday 6th

October 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

PATIENTS IDENTITY
Name
Sex
Age
Address
Occupation
Marital State

:
:
:
:
:

Mrs. S
Female
48 years old
Warurejo, Cilacap
Unemployed
: divorced

RELATIVEs
IDENTITY
Name
Age
Address
Occupation
Education
Relation with
patient
Duration of
Relationship

II

Mr. W
40 y.o
Cilacap
Employer
Senior High
School
Uncle

Mrs Sn
30 y.o
Pangandaran
Employed
Daughter
30 years

35 years
strong

Strength

strong

The Reason Patient was Brought

to Emergency Room
Patient has been :

Patient gets angry easily

Day dreaming
Patient often becomes raged
Patient deliberately destroys household
Patient talks to himself
Laugh by herself
Cry by herself
Pointless talk

STRESSOR

10 years ago, Patient was back from her Job in Arab

Saudi, she felt that she always sent her money to
her husband but her husband didnt use her money
well. Then she felt so dissapointed and divorced.

Present History of ilness

In 1994, , Patient was back from her Job in Arab Saudi, she
has known that her money didnt use well , then she
dissapointed.

IN 1997, she divorced and start day dreaming, talk by herself, laugh
by her self, talks to himself but not disturbed anyone. So her family
decided to not brought her to the hospital.
In 2004, her family decided to brought her to RSJ Banyumas because
of her agitation.

After her symptoms were gone, she stopped her medication.

In 2011, her symptoms come back but she didnt harm
others.
A week ago, she started to rampage, destroy household, and
bring sickle.

DAY OF ADMISSION
6th

October 2014

A week ago,
she started to
rampage,
destroy
household,
and bring
sickle.

Brought to hospital by
her daughter, mother
and uncle, because of:
-gets angry easily
-Day dreaming
-often becomes raged
-Deliberately destroys
household
-talks to himself
-Laugh by herself
-Cry by herself
-Pointless talk

Progression
of
Disorder
Symptom
1997

2004

2014

2011

Role of
function

Prenatal & Perinatal

Prenatal

Wanted pregnancy
Mother didnt complain any medical illness
(anemia, infection, hypertension, DM)
When her mother pregnant she was happy
over all

Perinatal

female baby, spontaneous crying, normal

birth weight (3000 gr) , aterm, from 32 y/o
mother P1A0, in traditional birth attendant.

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Her mother said that no delay in her development, she can
do same thing as her sister, but her mother forget about
the detail

Psychomotor

Psychosocial

There was no delay in communication aspect (such as bubbling, cooing,

making sounds without meaning, telling 2-3 syllables without meaning and
calling mama/papa)

Emotion

There was no delay in psychosocial aspect (such as replying to smile, smiling

when seeing interesting object, playing cilukba, knowing her family members
and pointing what she wanted without crying)

Communication

Patient could walk (9-12 months old) when she was 17 months old
There was no delay in other psychomotor aspect (such as tilting the body,
supine to prone, sitting, standing, smiling, holding her own hand, scoop up
object, holding pencil and pilling up two objects)

There was no delay In emotion aspect (such as when patient playing,

frightened by strangers, starting to show jealousy or competitiveness towards
other, and toilet training)
Patient didnt pee or defecate in her pants when she was two years old

Cognitive

There was no delay in cognitive aspect (such as copying sounds that she
heard for the first time and understanding simple orders)

INTERMEDIATE CHILDHOOD PHASE (3-11

YEARS OLD)

Psychomotor
Patient can play with her friend such as hide and seek,
skipping, and engklek.
Psychosocial
Patient is a sociable person, have a lot of friend
Communication
Patients ability to make friends at school is fair and
have few friends during childhood. No problem in
communication.
Emotional
Patient never get mad when she didnt get what she
want, eneuresis (-)
Cognitive
Patients academic history was good enough, she was
graduated from elementary school. But not continued
because of economic problem

LATE CHILHOOD & TEENAGE PHASE

Sexual development signs & activity
Patient first menstruation when she was at 6 th grade.
Psychomotor (NO VALID DATA)
No valid data on patients favourite hobbies or games, if
patient involved in any kind of sport.
Psychosocial
She is sociable person. She doesn't have any problem
with her family
Emotional (NO VALID DATA)
No valid data on patients emotional When she was teenage
Communication
Sociable person, and have many friend.

ADULTHOOD
Educational History
she was graduated from elementary school, and didnt
continue because of limitation of advanced education
facility problem
Occupational history
she was work as TKW in Arab Saudi for 5 years
Marital Status
married , she married a man by her choice and she felt
happy.
Criminal History
No criminal history
Social Activity
she is an extrovert person and she have many friends.
Her relation with her friends is good
Current Situation
she lives with her mother and her grand daughter.

FAMILY HISTORY
The

patient is the 1st child and has 1

sibling
No Psychiatry history in the family

GENOGRAM

48 yo old

PSYCHOSEXUAL
HISTORY
Patient realizes that he is
female
Has interests to male
Her attitude is appropriate as
a female

MENTAL STATE

Mental State

30h September 201

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

Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive
negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

EMOTION

DISTURBANCE OF
PERCEPTION

Depersonalization (-)

Derealization (-)

THOUGHT PROGRESSION

CONTENT OF THOUGHT

Delusion of grandiose

Idea of Reference

Idea of Guilt

Preoccupation

Obsession

Delusion of reference
Delusion of Influence
Delusion of Passivity
Delusion of Perception

Phobia

Delusion of Persecution

Delusion of Suspicious

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion

Delusion of Hipochondry Thought of withdrawal

Delusion of magic-mystic Thought of Broadcasting

FORM OF THOUGHT
Realistic
Dereistic
Non Realistic
Autism
Cannot be evaluated

SENSORIUM AND
COGNITION

Level of education
: Elementary
school
General knowledge
: Poor
Orientation of time
: poor
Orientations of place
: Poor
Orientations of people : Good
Orientations of situation : Poor
Working/short/long memory: not assessed
Writing and reading skills
: not
assessed
Visuospatial
: not assessed
Abstract thinking
: not assessed
Ability to self care
: Good

PHYSICAL STATE
Consciousness : compos mentis
Vital sign
Blood pressure
: 130/70 mmHg,
adult cuff, left handed
Pulse rate
: 84 bpm, regular
Temperature
: Afebrile
RR
: 20 x/mnt,
thoracoabdominal

REVIEW SYSTEM
Head
(-)

: normocephali, mouth deviation

Eyes

: anemic conjungtiva (-), icteric

sclera (-), pupil isocore

Neck

: normal, no rigidity, no palpable

lymph nodes
Thorax
Cor

: S 1,2 regular, no murmur heard

Lung : vesicular sound, wheezing -/-,

ronchi-/ Abdomen

: Pain (-) , normal peristaltic,

RESUME

A female, appropriate to her age,

completely clothed, fair appearance

Reason to be brought to hospital are:

gets angry easily
Day dreaming
often becomes raged
Deliberately destroys household
talks to himself
Laugh by herself
Cry by herself
Pointless talk

DAY OF ADMISSION

Mental
Status

gets
angry
easily
Day
dreaming
often
becomes
raged
Deliberat
ely
destroys
househol
d
talks to
himself
Laugh by

Impairment

- Affect: apropiate, labil

- Mood: dysphoric
- Behaviour: hypooactive
- Attitude: labil
- Perception: Hallucination
of auditory (+), visual (+)
- Thought Progression:
loggorhea, echolalia,
tangensial, loose
assiciation, irrelevant
answer, incoherence,
- Form of Thought: non
realistic
- Content of thought:
preoccupation
- Patients response to

- Didnt want
to work
- Impairment
social
- Can not
communica
te well with
other

Syndrome
of auditory (+), visual (+)

-Hallucination
-Tangential,

loose association
-Logorhea, ekholalia
-Expulsive
-Labile
-Dysphoric

mood
-Hypoactive
-Loss consentration
-Depressive

affect

scizophrenia
syndrome

Depressive
syndrome

Afective
syndrome

DIFFERENTIAL
DIAGNOSIS
F20.2 Schizofrenia Catatonic
F25.1 Schizoaffective depressive type

MULTIAXIAL
DIAGNOSIS
Axis I
: F25.1 Schizoaffective
depressive type
Axis II
: no diagnosis
Axis III : no diagnosis
Axis IV : Problem with economy
and family she divorced and start day
dreaming, talk by herself, laugh by her self, talks to
himself but not disturbed anyone. So her family
decided to not brought her to the hospital.

Axis V

: GAF admission 30-21

Patients problems

Biological problem

Psychological problems

Postive symptomps because of amount of

dopamine in the postsinaps neuron
She have economic problem with her husband

Social Problem

Didnt want to work

Impairment social
Can not communicate well with other

Management
Morning Report
Monday Octoberr 6th, 2014

PLANNING
MANAGEMENT
Inpatient (hospitalization):
gets angry easily
Day dreaming
often becomes raged
Deliberately destroys household
talks to himself
Laugh by herself
Cry by herself
Pointless talk

 Target

therapy :

50% decrease of symptoms

Response
Phase

Emergency
Diazepam

department

inj 5 mg iv (for sedative and muscle

relaxant)
Inj. Haloperidol 5 mg i.m ( to decrase positive
symptom in this patient)
Maintenance
Rasperidone

2mg po 2dd1

Remission Phase

Target therapy :

100% remission of symptom

Inpatient management

Risperidone 2mg 1ddI (decrease the side effect for longterm antypsycotic usage)
Improving the patient quality of life :

Teach patient about her social & environment (interact with

her family and child, socialize with her neighbor or friends, find
a hobby to do on her spare time)

Outpatient management

Pharmacotherapy
Psychosocial therapy

Recovery Phase
Continue

the medication, control

to psychiatric

Rehabilitation
-

:
Help patient to find a hobby,
Help patient to interact normally
with her family and neighbor
Family education

Family education

All people have a chance to have psychiatric

problem
Psychiatric problem caused by multifactorial
Most of psychiatric problem cause by imbalance of
neurotrasmitter in brain
Psychiatric symptom can be controlled by drugs
Treat patient as a normal person
Please, only help patient if she/he really need help.
Dont ask patient to understand the family
situation, but the family must understand the
patient situation.
Dont get easily angered to the patient.

Thank You