Tuesday 30th

September
2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

PATIENTS IDENTITY
Name
: Mrs. S
Sex
: Female
Age
: 25 years old
Address
: Condon, Temanggung,
Jawa
Tengah
Occupation
: Unemployed
Marital State : Married

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

II

Mr. NR
32 y.o
Condon,
Temanggung
Employer (in
Jakarta)
Senior High
School
Husband

Mrs. P
58 y.o
Temanggung
Farmer
Mother
25 years
strong

Strength

7 years
strong

The Reason Patient was

Brought to Emergency Room
Patient has been :
Day dreaming
Pointless talk
Laugh by herself
Cry by herself

STRESSOR

2 years ago, A house that Inherited by her

father in law, suddenly sold by her brother
in law without her and her husband
consent
Last Week Ask by her father about
motorcycle document (BPKB), when her
husband wasnt at home

Present
History
of
ilness
In 2012, A house that Inherited by her father in law,
suddenly sold by her brother in law without her and her
husband consent, then she shocked and start cries by
herself, pointless talk, and laugh by her self, and her
husband brought her to RSJ Magelang, and she treated
as out patient.
Shes not routinely controlled to RSJ, and only take her
medication when she has a complain, in daily routine the
patient can do all the household stuff.

A few month later, She didnt sleep for one week and
went to midwife and prescribe medicine for sleep. But
still can do all the household stuff as usual. She isnt look

DAY OF ADMISSION
24th

September 2014

Last 5 days
patient
Ask by her
father about
motorcycle
document
(BPKB), when
her husband
wasnt at
home

Brought to
hospital by his
husband and
father, because
of:
Day dreaming
Talk by herself
Cry by herself
Pointless talk

Progression of Disorder
Symptom
2012

2014

Role of
function

Prenatal & Perinatal

Prenatal
Wanted pregnancy
Mother didnt complain any medical
illness (anemia, infection, hypertension,
DM)
Prenatal care has given by midwife
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 P4A0, in midwifes clinic

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

Patient could walk (9-12 months old) when she was 2 years 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 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 6th grade.
Her only boyfriend now become her husband
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 economic problem
Occupational history
she was work as House maid in jakarta for 5 years, and
when she was back to temanggung, her boyfriend
proposed her and get married. She did well inher work.
Marital Status
married , dengan pilihannya gak? Bahagia gak? Boros
Criminal
atau hemat?
History
No criminal history
Social Activity
she is an extrovert person and she have many friends.
Her relation with her boss was fine.
Current Situation
she lives with her childrens and her husband who work
at jakarta (once a month back to temanggung)

FAMILY HISTORY
The patient is the 4th child and has 3
siblings, the first child was died
No Psychiatry history in the family

GENOGRAM

25 yr 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

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 Reference

Thought of Echo

Delusion of Envious

Thought of Insertion

Delusion of Hipochondry Thought of withdrawal

Delusion of magic-mystic Thought of Broadcasting

Delusion of Suspicious

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
: 110/70 mmHg, adult
cuff, left handed
Pulse rate
: 74 bpm, regular
Temperature
: Afebrile
RR
: 18 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:

Day dreaming
Pointless talk
Laugh by herself
Cry by herself

DAY OF ADMISSION

Mental
Status

- Affect: inapropiate, labil

- Mood: elevated
- Behaviour: normoactive

Day
dreaming
Pointless
talk
Laugh by
herself
Cry by
herself

- Attitude: labil
- Perception:
Hallucination of auditory
(+), visual (+)
- Thought Progression:
Remming, tangensial,
loose assiciation
- Form of Thought: non
realistic
- Content of thought: idea
of guilt
- Patients response to

Impairment
- Poor Spare
time
manageme
nt for child
and
husband
- Can not
communica
te well with
other

Syndrome
- Idea of guilt
- Hallucination of auditory (+), visual (+)
- Remming, tangential, loose association
- Labile, Inappropriate affect
- Elevated mood
- History decrease of sleep ( one week)

Psychotic
syndrome

Manic
syndrome

DIFFERENTIAL
DIAGNOSIS
F20.0 Schizophrenia Paranoid
F25.0 Schizoaffective manic type
F25.2 Schizoaffective Mixed Type

MULTIAXIAL
DIAGNOSIS
Axis I
: F20.0 Schizophrenia
paranoid
Axis II
: delayed diagnosis
Axis III
: no diagnosis
Axis IV
: Problem with
economy and family her father ask
for motorcycle document BPKB which
lent to her, which is that document was
mortgaged by her.

Patients problems
Biological problem
Postive symptomps because of amount
of dopamine in the postsinaps neuron

Psychological problems
She have economic problem with her
family and her family in law

Social Problem
She cant communicate with others,
leisure time with family is diminished

Morning Report
Friday September 26th, 2014

MANAGEMENT

PLANNING
MANAGEMENT
Inpatient (hospitalization):

Day dreaming
Pointless talk
Laugh by herself
Cry by herself

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
Haloperidol 5 mg po 2dd1
Re-assess patient

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 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