IDENTITY

Name : Ms. T
Age : 26 years old
Gender : Female
Address : Cilacap
Occupation : Unemployed
Marriage status : Not Married
Yet
Last education : JHS
Name : Mrs. S
Age : 53 years old
Relation : Mother
GUARDIAN
PATIENT

Talking and singing by herself, and
easily got angry




The reason patient was
brought to the hospital

STRESSOR
unclear

PRESENT HISTORY
3 years before, after dismissed from Banyumas
Hospital, the patient got to work again as housemaid
in Jakarta for a year, and got back to Cilacap because
of not feeling comfort in Jakarta. Up till now, she was
not working at all, and doing nothing at home.

She was oftenly daydreaming,
She didnt take her routine medication.
2011
- She didnt feel like to work at home.
- She utilized her leisure time doing nothing
- She barely took goodcare of herself

3 months before, the patient started unable to sleep, didnt
work at all at home, and occasionally easily got angry towards
her neighbors.
She threw away her foods whenever she was given food.
She often talk to herself more than before.
She cant do her usual work
Poor utilization of leisure time
She barely take care of herself
2014
PRESENT
HISTORY
Patient kept talking by
herself
Easily got angry
Day of admission
Brought to
RSJS ER
by her
mother

The patient was admitted to the
Psychiatric Unit of Banyumas
Hospital at 2011 because she was
oftenly talking to herself.
Psychiatric
history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
General
medical
history

Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (-)
Drugs, alcohol
abuse, and
smoking
history

Patients family can not recall any impairment on growth and development.
Other milestone can not be assessed properly.

Psychomotoric (no valid data)
There is no valid data when patient:
first time lifting the head (3-6 months) rolling over (3-6 months)
Sitting (7-8 months)
Crawling (6-9 months)
Standing (6-9 months)
walking-running (16 months)
holding objects in her hand (3-6 months)
putting everything in her mouth (3-6 months)

Psychosocial (no valid data)
Parents can not recall the times when 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)
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Communication (no valid data)
They were forgot on when patient started saying words 1 year like
mom or dad. (1 year old)

Emotion (no valid data)
They were forgot of patients reaction when playing, frightened by
strangers, when starting to show jealousy or competitiveness towards
other and toilet training.

Cognitive (no valid data)
They were forgot on which age the patient can follow objects,
recognizing her mother, recognize her family members.
They were forgot on when the patient first copied sounds that were
heard, or understanding simple orders.

Psychomotor (no valid data)
forgot on when patients first time playing hide and seek or if patient ever
involved in any kind of sports Psychosocial (no valid data)
forgot about patients social relation.
Communication (no valid data)
forgot regarding patient ability to make friends at school and how many
friends patient have during his school period
Emotional (no valid data)
forgot on patients adaptation under stress, any incidents of bedwetting were
not known.
Cognitive (no valid data)
forgot on patients cognitive.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Sexual development signs & activity (no valid data)
Patients menarche, etc.
Psychomotor (no valid data)
There is no valid data on patients hobbies
Psychosocial
The patient prefers to be at home than playing outside with
friends.
Emotional (no valid data)
There is no valid data on patients reaction on playing, scared,
showed jealously or competitiveness
Communication
Patient can communicate well.
LATE CHILDHOOD & TEENAGE PHASE

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
Eriksons stages of
psychosocial development

Family history
Patient is the 2nd child with two siblings
Psychiatry history in the family (+) on her
grandmothers brother
Genogram
Patient Psychiatric Disorder

Patient knows that she is female, her behavior is
appropriate for female, she is attracted to man.

Psychosexual history

Socio-economic history

Economic scale : average to low
Validity

Alloanamnesis : valid
Autoanamnesis : invalid

Progression of
disorder
Symptom
Role function
2011 2014
2013

Mental State
(Thursday 27th March 2014)
Appearance
A woman, appropriate to her age, completely
clothed
State of Consciousness
Cloudy
Speech
Quantity : decreased
Quality : decreased

Behaviour
Hypoactive
HYPERACTIVE
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

ATTITUDE
NON -COOPERATIVE
Indiferrent
Apathy
TENSION
Dependent
Passive
Infantile
DISTRUST
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excitement

Emotion
Mood
Euthymic
Elevated
Euphoria
Expansive
Disphoric
Irritable
Agitation
Cant be assesed
Affect

Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
Cant be assessed

Thought progression
Quantity
Logorrhea
Blocking
Remming
Mutism
Talkative
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia

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 Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicious
Thought of Echo
Thought of Insertion /
withdrawal
Thought of Broadcasting
Idea of suicide

Form of thought
Realistic
Non Realistic
Dereistic
Autistic


Sensorium and Cognition
Level of education : Cant be assessed
General knowledge : Cant be assessed
Orientation of time : Cant be assessed
Orientations of place : Cant be assessed
Orientations of peoples : Cant be assessed
Orientations of situation : Cant be assessed
Working/short/long memory : Cant be assessed
Writing and reading skills : Cant be assessed
Visuospatial : Cant be assessed
Abstract thinking : Cant be assessed
Ability to self care : Cant be assessed

Impulse control when
examined
Self control: Bad
Insight
Impaired insight
Intellectual Insight
True Insight

Internal Status
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/70 mmHg
Pulse rate : 112 x/mnt
Temperature : Afebris
RR : 24 x/mnt, regular


Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, tremor (-)
Neurological exam : not examined

Symptoms
Talking by herself

Easily got angry
to her NBs

Unable to start
sleeping

Mental Status
Behavior : not
cooperative
Attitude : tension,
distrust
Affect: restrictive
Mood: irritable
Form of thought:
autistic
Progression of thought:
Mutism, poverty of
speech
Perception: delusion of
suspicious
Insight: impaired
Impairment
Disturbance of
role function
She cant do her
usual work
Poor utilization
of leisure time
She barely take
care of herself


Differential Diagnosis

F20.0 Paranoid Schizophrenia
F25.1 Schizoaffective Depressive Type
F32.2 Severe Depressive Disorder with
Psycotic Sign

Multiaxial Diagnosis
Axis I : F20.0 Paranoid Schizophrenia
Axis II : delayed diagnosis
Axis III : no diagnosis
Axis IV : stressor unclear
Axis V : GAF on admission 30-21

1. Problem about patients family
unclear

2. Problem about social economy
The socioeconomic level is at average

3. Problem about patients biological state
In Schizophrenic patient, there is abnormal balancing of the
neurotransmitter (increasing of dopamine) which has the
contribution for the symptoms : talking by herself, delusion of
suspicious. We need pharmacotherapy for re-balancing the
neurotransmitter
Problem(s)
related to the patient

Inpatient (hospitalization)

Purpose of hospitalization is to decrease the
symptoms :
Talking by herself
delusion of suspicious
easily got angry
PLANNING MANAGEMENT
Response Remission Recovery

Target therapy : 50% decrease of symptom
(talking to herself, delusion of suspicious)

Emergency department
Antipsychotics : Inj. Haloperidol 5 mg i.m.
Sedative : Inj. Diazepam 10 mg i.v.

Maintenance
Risperidone 2 x 2 mg

Suggest :
Re-assess patient
Supportive therapy from family
RESPONSE PHASE

Target therapy :
100% remission of symptom within 4-9 months (talking to
herself, delusion of suspicious)

Inpatient management
1. Continue the pharmacotherapy:
Risperidone 2 x 2 mg
2. Improving the patient quality of life :
Teach patient about his social & environment
(back to work, moping, clean the floor, washing the
dishes, etc)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

REMISSION PHASE

Target therapy : 100% remission of symptom
within 1 year (talking to herself, delusion of
suspicious)
RECOVERY PHASE
Continue the medication, control
to psychiatric
Rehabilitation : help patient to
got & apply his skill
Family education

Thank you~
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