SUPERVISOR SUPERVISOR dr. Sabar P. Siregardr. Sabar P. Siregar, , Sp.KJSp.KJ

Monday 6th October 2014

PATIENT’S IDENTITYName : Mrs. SSex : FemaleAge : 48 years oldAddress : Warurejo, CilacapOccupation : UnemployedMarital State : divorced

RELATIVE’s IDENTITY I IIName AgeAddressOccupationEducationRelation with patient Duration of Relationship

Strength

Mr. W 40 y.oCilacap

EmployerSenior High

SchoolUncle

35 years

strong

Mrs Sn30 y.o

PangandaranEmployed

- Daughter

30 years

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 didn’t 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 didn’t 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 didn’t harm others. A week ago, she started to rampage, destroy household, and bring sickle.

DAY OF ADMISSION6th October 2014

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

A week ago, she started to rampage, destroy household,

and bring sickle.

Progression of DisorderSymptom 1997 2004

Role of function

2011

2014

Prenatal & Perinatal• Prenatal– Wanted pregnancy– Mother didn’t 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)EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

– Psychomotor• 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)

– Psychosocial• 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• 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 emotion aspect (such as when patient playing,

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

• Patient didn’t 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)

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

the detail

INTERMEDIATEINTERMEDIATE CHILDHOOD PHASE ( CHILDHOOD PHASE (3-113-11 YEARS OLD)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

– Patient’s 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 didn’t get what she

want, eneuresis (-) Cognitive

– Patient’s academic history was good enough, she was graduated from elementary school. But not continued because of economic problem

LATE CHILHOOD & TEENAGE PHASELATE CHILHOOD & TEENAGE PHASESexual development signs & activity

– Patient first menstruation when she was at 6th grade.

Psychomotor (NO VALID DATA)– No valid data on patient’s 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 patient’s emotional When she was teenage

Communication – Sociable person, and have many friend.

ADULTHOOD • Educational History

she was graduated from elementary school, and didn’t continue because of limitation of advanced education facility problem

• Occupational historyshe 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 HISTORYThe 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 State30h September 2014

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

• Idea of Reference• Idea of Guilt• Preoccupation• Obsession• Phobia • Delusion of Persecution• Delusion of Reference• Delusion of Envious• Delusion of Hipochondry• Delusion of magic-mystic

• Delusion of grandiose

• Delusion of reference

• Delusion of Influence

• Delusion of Passivity

• Delusion of Perception

• Delusion of Suspicious

• Thought of Echo

• Thought of Insertion

• Thought of withdrawal

• 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, tympany sound

Extremity : Warm acral, capp refill <2” Neurological exam : not examined

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

Mental Status 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

- Patient’s response to question: cooperative

- Impaired insight

• gets angry easily

• Day dreaming

• often becomes raged

• Deliberately destroys household

• talks to himself

• Laugh by herself

• Cry by herself

• Pointless talk

- Didn’t want to work

- Impairment social

- Can not communicate well with other

DDAY OF ADMISSIONAY OF ADMISSION

Syndrome-Hallucination of auditory (+), visual (+)-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 CatatonicF25.1 Schizoaffective depressive type

MULTIAXIAL DIAGNOSIS

Axis I : F25.1 Schizoaffective depressive type

Axis II : no diagnosisAxis III : no diagnosisAxis 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

Patient’s problems• Biological problem

– Postive symptomps because of amount of dopamine in the postsinaps neuron

• Psychological problems– She have economic problem with her husband

• Social Problem– Didn’t want to work– Impairment social– Can not communicate well with other

ManagementMorning ReportMonday Octoberr 6th, 2014

PLANNING PLANNING MANAGEMENTMANAGEMENT

Inpatient (hospitalization):gets angry easily

Day dreamingoften becomes raged

Deliberately destroys householdtalks to himselfLaugh by herself

Cry by herselfPointless talk

Response Phase Target therapy :

50% decrease of symptoms

Emergency department Diazepam 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 long-

term 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 PhaseContinue 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.• Don’t ask patient to understand the family

situation, but the family must understand the patient situation.

• Don’t get easily angered to the patient.

Thank You