Вы находитесь на странице: 1из 55

PRESENTATION CASE

WILA
WILA FAJARIYANTIKA
FAJARIYANTIKA
20110310129
20110310129

Supervisor :
dr. Sabar Parluhutan Siregar,
Sp.KJ

PATIENTS IDENTITY

Name
: Tn. M
Age
: 36 years
Religion
: Muslim
Address
: Magelang Tengah
Job
: not work
Marital Status : unmarried
Education Status : SD

PSYCHIATRIC HISTORY

CHIEF COMPLAINT
Angry and seizure

STRESSOR
Undifined

HISTORY OF PRESENT ILLNESS


2008
Patient get seizure, He tells that if he get tired he
started to seizure and he tells that when he get it he is
unconcious and feeling nothing. he was not gone to
hospital, his mother call their nurse neighbour

2010
Patient was brought to emergency department of RSJS
Magelang by his environment leader with weakness and
seizure history. Patient can get his seize anywhere.
When he got his seize he was unconcious. Patient feels
weak and didnt know nothing when he got it. Beside
that, patient tells that he can smeels kemenyan
everywhere. Patient cant walk and must use
wheelchair. He dont have any family after his mother
dead.
November 2015

Patient was hospitalized in RSJS magelang since 5 years


ago because he didnt have any family again. Patient
sometimes still got seizure but not as much as before.
Patient tells that he still can smeels kemenyan.

HISTORY OF PAST ILLNESS


History of

HISTORY OF PERSONAL LIFE

PRENATAL & PERINATAL


There was no valid data about prenatal history and
mother pregnancy and delivery, length of
pregnancy, spontaneity and normality of delivery,
birth trauma, whether the patient was planned or
wanted, and also any birth defect, how mothers
condition, and who was help of labor.
There was no valid data about the condition of
patient when she was born such as activity (muscle
tone), pulse, grimace (reflex irritability), appearance,
and respiration (APGAR score)
There was no valid data about feeding habits of
patient, is it breast feed or bottle feed, was he
having any eating problem.

DEVELOPMENTAL HISTORY (GROSS


MOTORIC)
Ability

Result

Normal range

Elevating the
head
Moving to supine
position on its
own
Sitting

No Valid Data

0-3 months

No Valid Data

3-6 months

No Valid Data

6-9 months

Standing

No Valid Data

9-12 months

Walking

No Valid Data

12-24 months

Climbing up the
ladder
Standing 1 foot /
jump

No Valid Data

24-36 months

No Valid Data

36-48 months3

DEVELOPMENTAL HISTORY (FINE MOTORIC)


Ability
Holding a pencil
Holding 2 objects at the
same time
Piling 2 cubes
Inserting objects into
container
Rolling a ball
Doodling
Wearing shirt

Result
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid

Normal range
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24-36 months
36-48 months

DEVELOPMENTAL HISTORY (LANGUAGE)

Ability

Result

Normal
range

Oooh-aah

No Valid
Data

0-3 months

Turning toward the sound

No Valid
Data

3-5 months

High-pitched sound

No Valid
Data

3-6 months

Voice without meaning (mamama,


Bababa)

No Valid
Data

6-9 months

Calling 2-3 syllables without meaning No Valid


Data

9-12 months

Calling 3-6 words that have meaning

No Valid
Data

18-24 months

Talking at least with two words

No Valid
Data

24-36 months

DEVELOPMENTAL HISTORY (SOCIAL &


PERSONAL)
Ability

Result

Normal range

Know their mother

No Valid Data 0-3 months

Reach out

No Valid Data 3-6 months

Clap

No Valid Data 6-9 months

Playing peek a boo

No Valid Data 6-9 months

Know their family

No Valid Data 9-12 months

Appoint what her wants


without crying or whining

No Valid Data 12-18


months

Tidy up toys

No Valid Data 24-36


months
No Valid Data 36-48
months

Playing with friends, follow


the rules of the game

There are

INTERMEDIATE CHILDHOOD
(3-11 YEARS OLD)

Psychomotor
Psychomotor (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on when
when patient
patient first
first time
time climbing
climbing the
the tree
tree or
or
play
play hide
hide and
and seek
seek games,
games, and
and if
if patient
patient ever
ever involved
involved in
in any
any
kind
kind of
of sports.
sports.

Psychosocial (NO VALID DATA)


There
There was
was no
no valid
valid data
data on
on patients
patients gender
gender identification,
identification,
interaction
interaction with
with his
his surrounding.
surrounding. There
There were
were no
no data
data on
on when
when
patient
patient first
first entered
entered primary
primary school,
school, how
how well
well patient
patient handle
handle
separation
separation from
from parents,
parents, how
how well
well she
she plays
plays with
with new
new friendson
friendson
first
first day
day of
of school
school

Communication
Communication (NO
(NO VALID
VALID DATA)
DATA)
There
There was
was no
no valid
valid data
data regarding
regarding patients
patients ability
ability to
to make
make
friends
friends in
in school,
school, and
and how
how many
many friends
friends patient
patient have
have during
during
her
her schooling
schooling period.
period.

Emotion
Emotion (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on patient
patient adaptation
adaptation under
under stress
stress


Sexual
Sexual Development
Development Sign
Sign and
and Activity
Activity (NO
(NO VALID
VALID
DATA)
DATA)
No
No data
data on
on when
when patient
patient first
first wet
wet dream,
dream, growth
growth hair
hair on
on
armpits,
armpits, growth
growth pubic
pubic hair,
hair, etc.
etc.

Psychomotor
Psychomotor (NO
(NO VALID
VALID DATA)
DATA)
No
No data
data if
if patient
patient had
had any
any favorite
favorite hobbies
hobbies or
or games,
games, if
if patient
patient
involved
involved in
in any
any kind
kind of
of sports.
sports.

Psychosocial
Psychosocial (( NO
NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on when
when and
and how
how patients
patients relationship
relationship with
with
different
different gender,
gender, if
if patient
patient ever
ever had
had any
any relationship
relationship with
with
opposite
opposite gender.
gender.

Communication
Communication (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on how
how well
well the
the relationship
relationship between
between patient
patient
with
with parents
parents and
and other
other family.
family.

Emotion
Emotion (NO
(NO VALID
VALID DATA)
DATA)
No
No data
data if
if patient
patient ever
ever told
told friend
friend or
or family
family regarding
regarding any
any
problems
problems
No
No data
data if
if patient
patient attempted
attempted to
to break
break the
the rules
rules (truant
(truant school
school

PRESCHOOL
Physical
Physically active
Rule of Three: 3 yrs,3
ft, 33 lbs.
Weight gain: 4-5 lbs
per year
Growth: 3-4 inches
per year
Physically active,
cant sit still for long
Clumsy throwing balls
Refines complex
skills: hopping,
jumping, climbing,
running, ride
bigwheels and
tricycles
Improving fine motor
skills and eye-hand
coordination: cut with
scissors, draw shapes
3 3,5 yr: most toilet

Cognitive
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, cant
represent themselves in drawing till
age 4
Dont realize others have
different perspective
Leave out important facts
May misinterpret visual cues of
emotions
Receptive language better
than expressive till age 4

Social
Play:
Cooperative,imaginati
ve, may involve fantasy
and imaginary friends,
takes turns in games
Develops gross and
fine motor skills; social
skills;
experiment with social
roles;reduces fears
Wants to please adults
Development of
conscience:
Incorporates parental
prohibitions; feels guilty
when disobedient;
simplistic idea of
good and bad
behavior
Curious about her and
others bodies, may

Emotional
Self-esteem based on what
others tell him or her
Increasing ability to control
emotions;
less
emotional
outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right
and wrong
Self-esteem reflects opinions
of significant others
Curious
Self-directed in many activities

Possible effects of maltreatment


Poor muscle tone, motor coordination
Poor pronunciation, incomplete sentences
Cognitive delays; inability to concentrate
Cannot play cooperatively; lack curiosity, absent
imaginative and fantasy play
Social immaturity: unable to share or negotiate
with peers; overly bossy, aggressive, competitive
Attachment problems: overly clingy, superficial
attachments, show little distress or over-react
when
separated from caregiver
Underweight from malnourishment; small stature
Excessively fearful, anxious, night terrors
Reminders of traumatic experience may trigger
severe anxiety, aggression, preoccupation
Lack impulse control, little ability to delay
gratification
Exaggerated response (tantrums, aggression) to
even mild stressors
Poor self esteem, confidence; absence of
initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses

SCHOOL AGED
Physical

Cognitive

Slow, steady
growth: 3 -4
inches per year
Use physical
activities
to develop gross
and fine motor
skills
Motor &
perceptual
motor skills better
integrated
10-12 yr: puberty
begins for some
children

Use language as acommunication


tool
Perspective taking:
5-8 yr: can recognize others
perspectives, cant assume the
role of the other
810 yr: recognize difference
between behavior and intent; age
10-11 yr: can accurately
recognize and consider
others viewpoints
Concrete operations:
Accurate perception of
events; rational, logical
thought; concrete thinking; reflect
upon self and attributes;
understands concepts of space,
time, dimension
Can remember events
from months, or years
earlier
More effective coping skills
Understands how his

Social
Friendships are situation
specific
Understands concepts
of right and wrong
Rules relied upon to
guide behavior and play, and
provide child with structure and
security
5-6 yr: believe rules can
be changed
7-8 yrs: strict adherence
to rules
9-10 yrs: rules can be
negotiated
Begin understanding social roles;
regards them as inflexible; can
adapt behavior to fit different
situations; practices social roles
Takes on more responsibilities at
home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self

Emotional

Possible effects of maltreatment

Self esteem based on ability to


perform and produce
Alternative strategies for dealing
with frustrationand expressing
emotions
Sensitive to others opinions
about themselves
6-9 yr: have questions about
pregnancy, intercourse, sexual
wearing, look for nude pictures
in books, magazines
10-12 yr: games with peeing,
sexual activity (e.g., strip poker,
truth/dare, boy-girl relationships,
flirting, some
kissing, stroking/rubbing,
reenacting intercourse with
clothes on)

Poor social/academic adjustment in school: preoccupied,


easily frustrated, emotional outbursts, difficulty
concentrating, can be overly reliant on teachers; academic
challenges are threatening, cause anxiety
Little impulse control, immediate gratification, inadequate
coping skills, anxiety, easily frustrated, may feel out of
control
Extremes of emotions, emotional numbing; older children
may self-medicate to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting,
lying, stealing, breaking objects, verbal outbursts,
swearing
Extreme reaction to perceived danger (i.e.,fight, flight,
freeze response)
May be mistrustful of adults, or overly
solicitous,manipulative
May speak in unrealistically glowing terms about his
parents
Difficulties in peer relationships; feel inadequate around
peers; over-controlling
Unable to initiate, participate in, or complete activities,
give up quickly
Attachment problems: may not be able to trust, tests
commitment of foster and adoptive parent with negative

ADOLESCENTS
Physical
Growth spurt:
Girls: 11-14 yrs
Boys: 13-17 yrs
Puberty:
Girls: 11-14 yrs
Boys: 12-15 yrs
Youth acclimate to
changes in body

Cognitive
Formal operations: precursors in early
adolescence, more developed in
middle and
late adolescence, as follows:
Think hypothetically: calculate
consequences of thoughts and
actions without experiencing them;
consider a number of possibilities and
plan behavior accordingly
Think logically: identify and reject
hypotheses or possible outcomes
based on logic
Think hypothetically, abstractly,
logically
Think about thought: leads to
introspection and selfanalysis
Insight, perspective taking:
understand and consider others
perspectives, and perspectives of
social systems
Systematic problem solving: can
attack a problem, consider multiple
solutions, plan a course of action
Cognitive development is uneven,

Social
Young (12 14):
Psychologically distance self
from parents;identify
with peer group; social status
largely related to group
membership; social
acceptance depends on
conformity to observable traits
or roles; need to be
independent from all adults;
ambivalent about
sexual relationships, sexual
behavior is exploratory
Middle (15 17):
friendships based
on loyalty, understanding,
trust; self-revelationis first step
towards intimacy; conscious
choices about
adults to trust; respect honesty
& straight for wardness from
adults; may become sexually
active
Morality: golden rule;

Emotional
Psycho-social task is identity
formation
Young adolescents (12-14):
selfconscious about physical
appearance and early or late
development; body image rarely
objective, negatively affected by
physical and sexual abuse;
emotionally labile; may over-react to
parental questions or criticisms;
engage in activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others values,
beliefs; forms identity by organizing
perceptions of ones attitudes,
behaviors, values into coherent
whole; identity includes positive
self image comprised of cognitive and
affective components
Additional struggles with identity

Possible effects of maltreatment


All of the problems listed in school age
section
Identity confusion: inability to trust in self to
be a healthy adult; expect to fail; may
appear immobilized and without
Direction
Poor self esteem: pervasive feelings of guilt,
self-criticism, overly rigid expectations for
self, inadequacy
May overcompensate for negative selfesteem
by being narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and
aggressive, antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with
frequent and violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders

ADULTHOOD
Occupational

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: no clear data

FAMILY HISTORY

There is no one of patient family that


have psyciatric problem
Epilepsi (-)
Hypertension (-)
Diabetes Mellitus (-)

GENOGRAM

PROGRESSION OF ILLNESS
SYMPTOMS
2010

ROLE
FUNCTION

2015

MENTAL STATE
Appearance
A men, appropriate to his age, wear complete
clothes, enough self care
State of Consciousness
Clear
Connection
a. Attention easily attained, sustained
concentration (+)
b. Attention easily attained, unable to sustained
concentration (-)
c. Difficulty to attention, unable to sustained
concentration (-)

Speech
Quantity
:
- Increase
Decrease
Quality
:
Decrease

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy

Normoactive

Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic

Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive

ATTITUDE
Cooperative
Non-cooperative
Indifferent
Apathy
Tension
Dependent

Infantile
Distrust
Labile
Rigid

Passive negativism
Catalepsy
Cerea flexibility
Excitement

Emotion
Mood

Dysphoric (+)
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation

Affect

Inappropriate
Appropriate
Restrictive
Blunted
Flat
Labile

Disturbance of Perception
Hallucination

Auditory
(-)
Visual
(-)
Olfactory
(+)
Gustatory
(-)
Tactile
(-)

Depersonalization (-)

Illusion

Auditory
Visual
Olfactory
Gustatory
Tactile

(-)
(-)
(-)
(-)
(-)

Derealisation (-)

Thought Progression
Quantity

Logorrhea
Talk active
Remming
Blocking
Mutism

Quality
Irrelevant answer (-)
Incoherence
(-)
Coherent
(-)
Flight of idea
(-)
Confabulasion
(-)
Verbigerasion
(-)
Preservasion
(-)
Poverty of speech(-)
Slow speech
(-)
Loosening of assosiasion (-)
Sound assosiasion
(-)
Circumstantiality
(-)
Tangential
(-)
Neologism
(-)
Word salad
(-)
Echolalia
(-)

Content of thought
Idea of Reference (-)

Delusion of Grandiose (-)

Idea of grandiose (-)

Delusion of Control(-)

Preoccupation
Obsession
Phobia

(-)

(-)

(-)

Delusion of Influence (-)


Delusion of Passivity (-)
Delusion of Perception (-)

of Persecution(-) Thought of Echo (-)


Thought Insertion (-)
Delusion of Reference (-)
Thought of withdrawal(-)
Delusion of Envious (-)
Delusion

Thought Broadcasting (-)


of Hypochondria (-)
Delusion of magic-mystic (-) Fantasy (-)
Delusion

Form of Thought
Realistic (+)
Non Realistic
Dereistic
Autistic

Impulse Control When


Examined

Self control
: Good
Patient response to examiners question :
Good

Insight
Impaired insight (+)
Intellectual Insight
True insight

Sensorium and Cognition

Level of education
: SD
General knowledge
: Bad
Orientation of time/place/people/situation
good/good/good/good
Working/short/long memory:
Good/Good/Good
Concentration
: Good
Writing and reading skills : Good
Ability to self care
: Good

PHYSICAL EXAMINATION
GENERAL PHYSICAL
EXAMINATION :
GENERAL APPEARANCE : COMPOS
MENTIS
VITAL SIGN
BP : 120/70 MMHG
HR : 96X/MINUTE
TO : 36O C
RR : 20X/MINUTE

Head : normocephali, mouth deviation (-),


anemic conjungtiva (-), icteric sclera(-),pupil
isocore (+)
Neck : normal, no rigidity, no palpable

lymph nodes
Thorax
Cor
: S1 S2 regular, murmur -, gallop Lung
: vesicular sound +/+, wh -/-, rh-/Abdomen : Flat, abdominal wall//chest wall,
normal peristaltic, tympany sound, tenderness -,
mass -, liver, spleen and kidney not palpable
Extremity : Warm acral, cappilary refill <2,
edema (-)

NEUROGICAL EXAMINATON

Interpretation :

Interpretation
NORMAL

CRANIAL NERVES EXAMINATION

Interpretation :

SIGNIFICANT FINDING RESUME


A
A woman
woman 36
36 years,
years, unmarried,
unmarried, not
not work,
work, hendicap
hendicap and
and familyless
familyless
Symptoms
Symptoms
Patient can get his
seize anywhere
When he got his
seize he was
unconcious.
Seizure since 7
years ago
He can smeels
kemenyan
everywhere

Mental
Mental status
status
Mood: Dhysporic
Insight: Impaired
Insight
Disturbance of
Perception:
Hallucination
Olfactory

Impairment
Impairment

Limited role
function

SYNDROME
Patient can get his seize
anywhere When he got his
seize he was unconcious.
Seizure since 7 years ago
He can smeels kemenyan
everywhere

syndrome organic
supposition

DIFFERENTIAL DIAGNOSIS

F06.0 Organic Hallucination

MULTIAXIAL DIAGNOSIS

PROBLEM RELATED TO THE


PATIENT
Problem

PLANNING MANAGEMENT

Responsive Phase

The target of therapy was 50% decrease


symptoms
Anti-anxiety

Risperidone 0,5 mg 2x1


Fenitoin 200 mg 2x1

Remission Phase
The target of therapy was 100% remission of
symptoms

Continue the pharmacotherapy

Improving the patient quality of life:


o Teach patient how to socialize to the environtment
(social skill training)

Recovery Phase

Target therapy was 100% remission of


symptoms
Rehabilitation:
Help patient to find a hobby
Help patient to socialize with other

PROGNOSIS

Quo
Quo
Quo
Quo
Quo
Quo

ad
ad
ad
ad
ad
ad

vitam
:: ad
vitam
ad bonam
bonam
sanationam
sanationam :: ad
ad bonam
bonam
social
social funtion
funtion :: dubia
dubia

THANK YOU