Morport Sabtu Ay-lia

7/28/2019 Morport Sabtu Ay-lia

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Thursday, 20th September 2012

Supervisor : dr Sabar P Siregar Sp.Kj


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Sufferers Identity

Name : Mr.AAge : 25 years oldGender : MaleAddress : BanjarnegaraOccupation : Unemployed

Marriage status : SingleReligion : MuslemLast education : Junior High School

Alloanamnesis

Name : Mrs. MAge : 45 years oldRelation : Patients Mother


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Chief complaint

Anger tantrums


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Assaults neighbours

Hearing voices

controlling him Sees supernatural being

Patient felt being pushed

by non-existent person

till patient fell down.

Did not take medications

Talks to himself & laughs

by himself.

Agitated & sensitive,

short tempered

Anger tantrums (no

reason) : throwing

furniture and assaulting

family members.

Presenting illness

1 year ago


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Today

Brought to hospital today because just found

financial support


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HISTORY OF PRESENT ILLNESS

Psychiatry history

Social withdrawal since8.5 years ago.

Hallucinations,Delusions,disorientation since 8years ago.

Hospitalization 10 x inRS Banyumas.

Medications notroutinely taken

Stressor unclear

General medical history

Head injury (+) 8 yrsago

Convulsion (-)

Asthma (-)

Allergy (-)

Drugs and alcohol abusehistory and smoking

history

Alcohol consumption (-)

Tobacco consumption(+)

Drugs abuse (-)


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History of Personal Life

PRENATAL AND PERINATAL HISTORY No significant abnormality medical conditions & nutritions

during the mothers pregnancy.

No significant abnormality regarding patients birth and

birth conditions.

Patient was born at home with the help of a traditional

midwife.


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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, rolling over, sitting, crawling,

standing, walking-running, holding objects in her hand, putting

everything in her mouth, holding objects in her hand

Psychosocial

There were no valid data on which age patient started smiling

when seeing another face, startled by noises, when the patient

first laugh or squirm when asked to play, nor playing claps with

others

Communication

There were no valid data on when patient started saying words

like mom or dad, or talks.


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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 her mother,recognize her family members.

There were no valid data on when the patient first copied

sounds that were heard, or understanding simple orders.


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Intermediate Childhood (3-11 years

old) Psychomotor

No valid data on when patients first time riding a tricycle or bicycle, if patientever involved in any kind of sports.

Psychosocial

There were no data on patients gender identification, interaction with her

surroundings

There were no data on when patient first entered primary school, how well

patient handles seperation from parents, how well she plays with new friendson first day of school

Communication

There were no valid data regarding patients ability to make friends in school,

and how many friends patient had during her schooling period.

Emotional

No valid data on patients adaptation under stress, any incidents ofbedwetting were not known.

Cognitive

No valid data on patients achievement in school, how well patient;s reading

ability and grades.


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Late Childhood & Teenage Phase Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpits andpubis, etc

Psychomotor

No valid data if patient had any favourite hobbies or games, if patient involved

in any kind of sports.

Psychosocial

Patient had many friends and did not have any known problem with friends. It is unknown if patient had any friends from the opposite gender at this page.

Emotional

No valid data if patient ever told friends or family regarding any problems.

No valid data if patient attempted to break the rules (truant schools subject,

fight with friends, bullying, etc) and consuming alcohol, smoke and drugs

Communication No valid data on how well the relationship between patient with parents and

other family.


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Family History

Patient is the eldest child of 4 siblings.

Stays with his mother and sick father at

home.

There is a history of psychiatric disorder

(type unknown) in late grandmother.


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Psychosexual history

Patient psychosexual history is appropriate of

his gender and attracted to female

Had a girlfriend but broke off 2 years ago.


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Genogram


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Economically supported by father andmother.

Socio-economic status : Low

Socio-economic

history

Alloanamnesis : valid Autoanamnesis : not validValidity


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Progression of Ilness

symptom

Role function

5 years ago8 yrs ago 1 year ago till now


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Mental State

Appearance :

Male, 25 years old, appropriate for age, satisfactory

grooming

State of Consciousness

Clouded

Speech:

Quantity: increased

Quality: poor


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Behaviour

Hypoactive

Hyperactive

Normoactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

MannerismAutomatism

Command automatismMutism

Acathysia

Tic

SomnabulismPsychomotor agitation

Compulsive

Ataxia

Mimicry

AggresiveImpulsive

Abulia


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ATTITUDE

Non-cooperative

Cooperative

Indiferrent

Apathy

Tension

Dependent

Active

Passive

Infantile

Distrust

Labile

RigidPassive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcitement


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Emotion

Mood

Euthymic

Dysphoric

Euphoria

Elevated

Expansive

Irritable Cant be assesed

Affect

Appropriate

Inappropriate Restrictive

Blunted

Flat

Labile


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Disturbance of perception

Hallucination

auditory

Visual (-)

Olfactory (-)

Gustatory (-) Tactile (-)

Somatic (-)

Cannot be assessed

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-) Tactile (-)

Somatic (-)

Cannot be assessed

Derealisation (-)Depersonalisation (-)

Thi ki


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Thinking

thought progression

Quantity

Logorrhea

Blocking

Remming

Mutisme

Talk active

QualityIrrelevant answer

Coherence

Confabulation

Poverty of speech

Flight of idea

Sound association

Loosening of association

Incoherence

Word salad

NeologismeCircumstantiality

Tangentiallity

Verbigration

Perseveration

Echolalia


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Idea of Reference

Preoccupation

Obsession

Phobia

Delusion of pursue

Delusion of suspicious

Delusion of envious

Delusion of hipochondria

Delusion of magic-mistic

Delusion of control

Delusion of influence

Delusion of passivity

Delusion of perception

Delusion of grandeur

Thought of echo

Thought of insertion/withdrawalThought of broadcasting


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Thought process

Form of Thought

Realistic

Non RealisticDereistic

Autistic


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Sensorium and Cognition

Level of education : enough

General knowledge : Cannot be assessed

Orientation of time/place/people/situation:

poor/poor/poor/poorMemory : cannot be assessed

Writing & reading : cannot be assessed

Visuospatial : cannot be assessedAbstract thinking : cannot be assessed

Ability to self care : cannot be assessed


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PoorImpulse controlwhen examined

Impaired insight

Intellectual Insight

True Insight

Insight


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Internal Status

Conciousnes: compos mentis

Vital sign:

Blood pressure : 120/80 mmHg

Pulse rate : 82 x/mnt

Temperature : 36.6C

RR : 20 x/mnt


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Head: mesocephali

Eyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil isocor

Neck: normal, no rigidity, no palpable lymphnode

Thorax:

Cor: S1 and S2 sound and normal

Lungs: vesicular sound, wheezing -/-, ronchi-/-

Abdomen: pain -, peristaltic normal, thympany sound

Extremity: acral temperature, cappillary refill < 2 second


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Neurological status

Motoric: normotonus, good coordination of

movement

Physiological reflex: +/+

Pathological reflex: -/-


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SIGNIFICANT FINDING RESUME Onset: 1 year ago

Stressor: Unknown

Symptoms

Anger tantrums, Agitatedand sensitive

Hearing voices, seessupernatural being

Assault neighbours

Disability

- Unemployed

- Sociallyaggressive

- Day dreamduring free

time

- Bad Selfgrooming

Mental Status

Orientation : PoorConsciousness : Clouded

Behaviour : Hyperactive,Psychomotor agitation

Attitude : Non cooperative

Mood : Irritable ; Affect : labileThought progression : logorrhea,

tangentiality

Form of thought : Autistic

Insight : Impaired

Talk and laugh by himself


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Differential Diagnose

F 20.0. Paranoid Schizophrenia

F20.2 Catatonic Schizophrenia

F 30.2 Mania with Psychotic Symptoms


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Multiaxial Diagnose

Axis I : F 20.0 Paranoid Schizophrenia

Axis II : Z03.2 No diagnosis

Axis III : None

Axis IV : unclear stressor

Axis V : GAF admission 20-11

The highest GAF in a year : 20-11


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Therapy

Hospitalization

To establish an effective association between

patients and community support systems

Hospital treatment plans should be orientedtoward practical issues of self-care, quality of life,

employment, and social relationships


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Therapy in ER

Inj. Haloperidol 5 mg IM

Inj. Diazepam 5 mg IV

Therapy in Ward

Haloperidol tab 2 x 5 mg

Suggestion for ECT if there is not relative

contraindication Psychosocial Therapy

Family oriented therapy


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PROGNOSIS

Ad vitam : dubia ad bonam

Ad functionum : dubia ad malam

Ad sanationum : dubia ad malam


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Thank you

Morport Sabtu Ay-lia

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