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8/12/2019 morport irvan

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SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

Saturday, May 24th 2014


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Patient IdentityAutoanamnesis

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


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Reason patient was brought

to emergency room

Patient feel very exhausted everyday

and doesnt work for a 12days


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Stressor

Divorced with her husband


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Past History

Patient has no psychiatricproblems before


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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


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Day of Admission

24th May 2014

atient brought with the complaints of

Patient always feel exhaustedPatient lost of interest in her hobby

Patient no appatite

Patient Cant concentrate

Cant start to sleepFeel guilty

Brought to hospital byhis 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


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PSYCHIATRIC HISTORY

Patient has no psychiatric problems

history before


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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)


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Communication

There were no valid data on when patient started bubbling. (6-9 months)

Emotion

There were no valid data of patientsreaction 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 thatwere heard, or understanding simple orders.


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INTERMEDIATE CHILDHOOD (3-11 YEARS

OLD)

PsychomotorNo valid data on when patientsfirst 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 patientsemotional.

Cognitive

No valid data on patientscognitive.


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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 patientsemotional.

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


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ADULTHOOD

Educational HistoryHe finished senior high school

Occupational History

she started to work as a textileemployment when she was

20 year old.

Her mother didntknow

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 SituationShe lives with her parents, being alone.

And she wasnt working as a driver


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Eriksons stages

of psychosocial developmentStage 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


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FAMILY HISTORY

Patient is the only child

There is no psychiatry history in the family


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Male Female Patient Divorced

GENOGRA

M


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PSYCHOSEXUAL HISTORY

Patient realizes that he is a female, and interested in

male. His attitude is appropriate as a female.


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Socio-economic history

Economic scale : low

Validity

Alloanamnesis: valid

Autoanamnesis: valid


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Progression of Disorder

Symptom

Role Function

2011 2014


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Appearance

A female, appropriate to his age, completely

clothed, nicely groomed

State of Consciousness

Clear

Speech

Quantity : Normal

Quality : Normal

Mental StateMay 24th2014


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BEHAVIOUR

Hypoactive

Hyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

AutomatismBizzare

Command automatism

Mutism

Acathysia

Tic

SomnabulismPsychomotor agitation

Compulsive

Ataxia

Mimicry

AggresiveImpulsive

Abulia


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ATTITUDE

Non-cooperative

Indiferrent

Apathy

Tension Dependent

Passive

InfantileDistrust

Labile

Rigid

Passive negativismStereotypy

Catalepsy

Cerea flexibility

Excited

Stable


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Emotion

Mood

Dysphoric

Euthymic Elevated

Euphoria

Expansive

Irritable

Agitation

Cant be assesed

Affect

Inappropriate

Broad Restrictive

Blunted

Flat

Labile


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Disturbance of Perception

Hallucination

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Depersonalization (-) Derealization (-)


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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


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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


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Form of Thought

RealisticNon Realistic

DereisticAutism

Cannot be evaluated


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Sensorium and Cognition

Level of education : finished junior highschool

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


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Physical State

Consciousnes : compos mentis

Vital sign :

Blood pressure : 129/76mmHg

Pulse rate : 100x/min

Temperature : Afebrile

RR : 22 x/min


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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


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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.


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Differential Diagnosis

F25.3 Schizo affective disorder depression type

F32.2 Depression without psychotic symptom

F43.2 Post Traumatic Stress Disorder


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Multiaxial Diagnosis

Axis I : F32.2 Depression without psichotic

symptom

Z91.1 Noncompliance of medicationAxis II : R46.8 Delayed diagnosis of Axis II

Axis III : no diagnosis

Axis IV : Divorcee with her husband

Axis V : GAF admission 40-31


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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


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PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION)

To reduce 50% the symptoms :

- Always feel exhausted

- Easily tired

- Lost in interest

- No appatite

- Cant cocentrate

Response Remission Recovery


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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 dayClobazam Tab 1x10 mg malam hingga 2 minggu lalu teppering

off (sedative)

Re-assess patient


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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


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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


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