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Sunday, 24thNovember 2013Supervisor : dr Sabar P Siregar Sp.KJ

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Wandering and confuse since 4days ago

Talking and laughing to herown self

Disturbing her neighbour

Difficult to sleep Gain appetite

has very low self esteem

Difficult to maintain herconcentration

lazy to go to work.

4 days

ago

Still wandering and confuse

She was crying all day longThe dayin patient

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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 5months, and she told her mother that her friends are being meanto her.

And then, she went back home and applied a job in Solo as acashier in a department store. But the same things happenedagain. 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 towork.

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 hardfor her to concentrate and understand the contain of the tv show.

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Psychiatry history

She have beenhospitalized twice in

Puriwaluyo Hospitalin Juni and July forabout 10 days each.

Her mother broughther to anotherdoctor in Kentingan,

and had been adviceto going to SoerojoPsychiatric HospitalMagelang.

General medicalhistory

Febrile Seizure (-)

Epilepsy (-)

Trauma (-)

Drugs and alcoholabuse history andsmoking history

Alcohol consumption(-)

Tobacco consumption(-)

Drug abuse (-)

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Her mother is 23 years old when she concievethe patient. She doesnt have history of

illness during pregnant, the delivery isnormal, aterm, assisted by traditional birthattendants.

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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.

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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 soundsthat were heard, or understanding simple orders.

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Psychomotor (NO VALID DATA)

No valid data on when patientsfirst 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)

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

final exam until senior high school.

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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 achef, she told her mother that she didnthave 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 patientwent to Kalimantan, she lost contact with him.

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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.

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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

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HISTORY

FAMILY HISTORY

The 2ndchild from 3

siblings She has 2 sisters No other member of her

family having the samesymptoms as her.

PSYCHOSEXUAL HISTORY

Patient psychosexual

history is appropriate ofher gender. She sure sheis female, and sheattracted to anothergender.

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Male

Female

Patient

Passed

away

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Socio-economic history

Economical scale : low

Validity

Alloanamnesis : valid Autoanamnesis : valid

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Symptoms

Role offunction

June2013

The Day inPatient

July2013

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Mental State

(Sunday, 24thNovember 2013)

Appearance :

A girl, appropriate according to her age, wear complete

clothes, good self grooming

State of Consciousness

Clear

Speech:

Quantity : increased

Quality : decreased

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BEHAVIOURNormoactiveHypoactiveHyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

Automatism

Bizarre

Command automatism

MutismAcathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive

Ataxia

Mimicry

Aggressive

Impulsive

Abulia

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ATTITUDE

CooperativeNon-cooperative

Indiferrent

Apathy

Tension

Dependent

Active

Passive

Infantile

Distrust

Labile

Rigid

Passivenegativism

Catalepsy

Cerea flexibility

Excitement

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Mood

Dysphoric

Euthymic Elevated

Euphoria

Expansive

Irritable Sad

Depressed

Cant be assesed

Affect

Appropriate

InappropriateRestrictive

Blunted

Flat

Labile

EMOTION

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Disturbance of perception

Hallucination

Auditory (+)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-) Undeferrentiated (-)

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Undeferrentiated (-)

Depersonalisation (-) Derealisation (-)

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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

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Content of Thought

Idea of Reference

Preocupation

Obsession

Phobia

Delusion of Persecution

Delusion of Reference

Delusion of Envious

Delusion of Hipokondry

Delusion of magic-mystic

Delusion of grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Delusion of Perception

Thought of Echo

Thought Insertion/withdrawal

Thought Broadcasting

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Thought process

Realistic

Non RealisticDereistic

Autistic

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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

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Impulse control when examined

Self control : enough

Patient response to examiners question: good

Insight

Impaired insight

Intellectual Insight

True Insight

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nternal Status

Conciousnes : compos mentis

Vital sign:

Blood pressure : 110/80 mmHg

Pulse rate : 88 x/minute

Temperature : afebris

RR : 20 x/minute

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Motoric : Normotones, good coordination ofmovement

Meningeal sign : negative Physiologic reflect : +/+ Patologic reflect : -/-

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Onset: 4 days ago

Stressor : Her relationship with her boyfriend

Symptoms

Wandering and confuse since 4 daysago

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.

Impairment

-Unemployed

-Socialwithdrawal

Mental Status

Behaviour : Hypoactive

Attitude : Cooperative, dependent

Mood : irritable, sad, depressed

Affect : aproppriate

Thought progression : talkactive

Form of thought :Non-realistic

Disturbance of perception:auditoric hallucination

Insight : intellectual insight

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Differential Diagnose

F32.3 Severe Depression with psychoticsymptoms

F25.1 Schizoaffective-Depression type

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Multiaxial Diagnosis

Axis I : F32.3 Severe Depression with

psychotic symptoms

Axis II : F60.1 Schizoid Personality Disorder

Axis III : No diagnosisAxis IV : Problems with primary support

group

Axis V : GAF admission 30-21

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Hospitalization

Pharmacotherapy

Psycho-education after

medication

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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.

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Pharmacotherapy

O Emergency Room:

- Inj Diazepam IV

- Inj Haloperidol 5mg IM

O Routine therapy

- Risperidon 2 x 1

- Fluoxetine 1 x 20 mg

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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.

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Thank you