SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

Saturday, May 24th 2014
Patient Identity
Autoanamnesis
Name : Mrs. U
Sex : Female
Age : 22 years old
Address : Krandan kebonrejo Salaman Magelang
Occupation : Textile employment
Marital State : Divorcee
Alloanamnesis
Name : Mrs. K
Sex : Female
Relation : Mother



Reason patient was brought
to emergency room
Patient feel very exhausted everyday
and doesnt work for a 12days
Stressor
Divorced with her husband
Past History
Patient has no psychiatricproblems before




Past History
Patient got married with her husband
Patient got an info that her husband cheating her
Patient force her husband to leave her parent house
Patient officialy divorced with her husband
Patient officialy divorced with her husband
Day of Admission




24th May 2014
Patient brought with the complaints of
Patient always feel exhausted
Patient lost of interest in her hobby
Patient no appatite
Patient Cant concentrate
Cant start to sleep
Feel guilty

Brought to hospital by
his mother


Now patient didnt worked as a Textile employment for 12 days
Poor utilization of leisure time
Sometimes took a wrong way to go to her house
PSYCHIATRIC HISTORY
Patient has no psychiatric problems
history before

General
medical history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol
abuse history and
smoking history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (-)
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric
- 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
- 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
There were no valid data on when patient started bubbling. (6-9 months)

Emotion
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
- There were no valid data on which age the patient can follow objects,
recognizing his mother, recognize his family members.

- There were no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.
INTERMEDIATE CHILDHOOD (3-11 YEARS
OLD)

Psychomotor
No valid data on when patients first time playing hide and seek
or if patient ever involved in any kind of sports.
Psychosocial
No valid data regarding patient psychosocial.
Communication
No valid data regarding patient ability to make friends at school
and how many friends patient have during his school period
Emotional
No valid data on patients emotional.
Cognitive
No valid data on patients cognitive.
LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)
No data on when patient first experience of wet dream, ect.

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

Psychosocial (NO VALID DATA)
No valid data regarding patient psychosocial.

Emotional (NO VALID DATA)
No valid data on patients emotional.

Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school
and how many friends patient have during his high school period
ADULTHOOD

Educational History
He finished senior high school

Occupational History
she started to work as a textile
employment when she was
20 year old.
Her mother didnt know
anything about her occupation.

Marital Status
Married once in 19 yo.
she was good wife and
has live in harmony with
her husband.


She doesnt have any
children with her husband

Criminal History
No

Social Activity
She was a friendly girl and had many
friends

Current Situation
She lives with her parents, being alone.
And she wasnt working as a driver
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
FAMILY HISTORY
Patient is the only child

There is no psychiatry history in the family

Male Female Patient Divorced
GENOGRA
M
PSYCHOSEXUAL HISTORY
Patient realizes that he is a female, and interested in
male. His attitude is appropriate as a female.
Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
Progression of Disorder
Symptom
Role Function
2011 2014
Appearance
A female, appropriate to his age, completely
clothed, nicely groomed
State of Consciousness
Clear
Speech
Quantity : Normal
Quality : Normal
Mental State
May 24
th
2014
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
Excited
Stable
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Inappropriate
Broad
Restrictive
Blunted
Flat
Labile
Disturbance of Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
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
Verbigration
Perseveration
Sound association
Word salad
Echolalia
Content of Thought
Idea of Reference
Idea of Guilt
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of Magic-mystic
Delusion of Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicion
Thought of Echo
Thought of Insertion & withdrawal
Thought of Broadcasting
Form of Thought
Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition
Level of education : finished junior high
school
General knowledge : good
Orientation of time : good
Orientations of place : good
Orientations of people : good
Orientations of situation : good
Working/short/long memory: good
Writing and reading skills : good
Visuospatial : good
Abstract thinking : good
Ability to self care : good


Self control: enough
Patient response to
examiners question:
good

Impaired insight
Intellectual Insight
True Insight
Impulse control
when examined
Insight
Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 129/76mmHg
Pulse rate : 100x/min
Temperature : Afebrile
RR : 22 x/min
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
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, motoric strength
Neurological exam : not examined
Mental Status Impairment

- Behavior: hypoactive
- Mood: Dysphoric
-Thought Progression: -
- Form of Thought : -



Patient always feel
exhausted

Patient lost of interest
in her hobby

Patient no appatite

Patient Cant
concentrate

Cant start to sleep

Feel guilty
Patient doesnt work
for a 12days

Patient has a poor
utilization of her
leisure time
Patient sometimes
confuse to choose
wich way to go to her
house
Symptoms
Patient is a female, 22 years old, nicely groomed,
has no history of admittion in psychiatric ward.
Differential Diagnosis

F25.3 Schizo affective disorder depression type
F32.2 Depression without psychotic symptom
F43.2 Post Traumatic Stress Disorder


Multiaxial Diagnosis
Axis I : F32.2 Depression without psichotic
symptom
Z91.1 Noncompliance of medication
Axis II : R46.8 Delayed diagnosis of Axis II
Axis III : no diagnosis
Axis IV : Divorcee with her husband
Axis V : GAF admission 40-31

1. Problem about patients life
- Patient married with her husband in 19 years old .
- Patient leave with her husband in her parent house
- When 2 Months of their marrital age, patient got an info that her husband
cheating her
- When patient got a mad with her husband, her husband slap her
- Patient force her husband to leave her parent house
- Patient resolving her divorcing status to the court alone

2. Problem about patients biological state
There were abnormality imbalance neurotransmitter, decrease of
serotonin, dopamine and norepinephrinne. So the patient need
psychopharmacology


PROBLEM RELATED TO THE PATIENT
PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
To reduce 50% the symptoms :
- Always feel exhausted
- Easily tired
- Lost in interest
- No appatite
- Cant cocentrate
Response Remission Recovery
RESPONSE PHASE
Target therapy :
50% decrease of symptoms

Emergency department
Diazepam 5 mg IV (sedation)
Haloperidol Inj. 1 amp. IM

Maintenance
fluoxetine 1x10 mg per day
Clobazam Tab 1x10 mg malam hingga 2 minggu lalu teppering
off (sedative)

Re-assess patient
Target therapy :
100% remission of symptom

Inpatient management
1. Continue the pharmacotherapy: maintenance Fluoxetin 1x10mg &
clobazam Tab 2x10 mg
2. Improving the patient quality of life :
Teach patient about her social & environment
( interact with her family, socialize with her neighbor or friends, find a
hobby to do on his spare time)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

REMISSION PHASE
RECOVERY PHASE
Target therapy :
100% remission of symptom
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