Saturday, 7th December 2013 Supervisor : dr. Sabar P. Siregar, Sp.KJ

Name: Mr. D Age: 23 years oldGender: MaleAddress: MagelangOccupation: unemployedMarriage status: not marriedLast education: Senior high school

Patient IdentityAlloanamnesisName : Mr. KAge : 40 years oldRelation : Brother

Causes brought the patient to the hospital

Presenting illness

Presenting illness

Presenting illness

PRESENTING ILLNESS (CONTD)

HISTORY OF PRESENT ILLNESS

PRENATAL AND PERINATAL HISTORY No significant abnormality medical conditions & nutritions during the motherss pregnancy.No significant abnormality regarding patients birth and birth conditions. Patient was borned in indigenous medical practitionerHistory of Personal Life

Psychomotoric (No Valid Data)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 his hand, putting everything in his mouth, holding objects in his handPsychosocial (No Valid Data)There were no valid data on which age patient started smiling when seeing anothers face, startled by noises, when the patient first laugh or squirm when asked to play, nor playing claps with others.Communication (No Valid Data)There were no valid data on when patient started saying words like mom or dad, or talks.Early Childhood Phase (0-3 years old)

Emotion (No Valid Data)There were no valid data of patients reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards othis and toilet training.Cognitive (No Valid Data)There were no valid data on which age the patient can follow objects, recognizing his mothis, recognize his family members. There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders.Early childhood phase ( contd)

Psychomotor (No Valid Data)No valid data on when patients first time play hiding, if patient ever involved in any kind of sports.Psychosocial (No Valid Data)There were no data on patients gender identification, interaction with patient surroundings but the patient usual to isolate patient self.There were no data on when patient first entered primary school, how well patient handles seperation from parents, how well he plays with new friends on first day of schoolCommunication (No Valid Data)There were no valid data regarding patients ability to make friends in school, and how many friends patient have during his schooling period.Emotional (No Valid Data)No valid data on patients adaptation under stress, any incidents of bedwetting were not known.Cognitive (No Valid Data)No valid data on patients achievement in school, how well patients reading ability and grades.Intermediate Childhood (3-11 years old)

Sexual development signs & activity (No Valid Data)No valid data on when patient experience wet dream, hair on armpits and pubis, etcPsychomotor (No Valid Data)No valid data if patient had any favourite hobbies or games, if patient involved in any kind of sports.Psychosocial (No Valid Data)While growing up patient make many friends, had much friendsPatients had relationship with different gender, had relationship with the opposite gender.Emotional (Not Valid Data)patient had no family regarding or any problems with others people.Patient not break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugsCommunication (No Valid Data)Well relationship between patient with parents and other family.Late Childhood & Teenage Phase

Eriksons stages of psychosocial development

StageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on life

Adulthood

Patient is the 2nd child from 3 siblings. There is no physichiatric disorder on his familyFamily History

Patient psychosexual history is appropriate to his gender and behaves according to his gender.

Psychosexual history

GenogramManWomanPatient

Progression of IlnesssymptomRole function3 years ago The day patient in 1 years ago3 months ago

Appearance : Look man according to his age, wearing shirts and trousers, bad groomingState of ConsciousnessClearSpeech:Quantity: increaseQuality: decreaseMental State (Saturday 7 th December 2013)

Behaviour HypoactiveNormoactiveHyperactive (+)EchopraxiaCatatoniaActive negativismCataplexyStreotypyMannerismAutomatismCommand automatismMutismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia

ATTITUDECooperativeNon-cooperative (+)IndiferrentApathyTensionDependentActivePassiveInfantileDistrustLabileRigidPassive negativismStereotypyCatalepsyCerea flexibilityExcitement

Emotion

Disturbance of perceptionDerealisation (-)Depersonalisation (-)

thought progressionIrrelevant answerIncohisenceFlight of ideaConfabulationPoverty of speechLoosening of associationNeologismeCircumstansiality (+)TangentiallityVerbigrationSound associationPerseverationWord saladEcholalia

Idea of refferencePreokupasiObsesiFobiaDelusion of pursued (+)Delusion of suspicious (+)Delusion of referenceDelusion of hipokondri

content of thoughtDelusion of magic-misticDelusion of controlDelusion of influenceDelusion of passivityDelusion of perceptionDelusion of grandeurThought of echoThought of insertion/withdrawalThought of broadcasting

Form of Thought

Level of education: educatedGeneral knowledge: goodOrientation of time/place/people/situation: Good/Good/Good/GoodWorking/short/long memory: not examinedWriting and reading skills: not examinedVisuospatial: not examinedAbstract thinking: not examinedAbility to self care: EnoughSensorium and Cognition

Conciousnes : ComposmentisVital sign:Blood pressure: 110/70 mmHgPulse rate : 70 x/mntTemperature : Afebrile RR: 20 x/mnt

Internal Status

Head: normocephaliEyes: anemic conjungtiva -/-, ikteric sclera -/-, pupil isocorNeck: normal, no rigidity, no palpable lymphnodeThorax:Cor: S1 and S2 sound and normalLungs: vesicular sound, wheezing -/-, ronchi-/-Abdomen: pain -, peristaltic normal, thympany sound Extremity: acral temperature, cappillary refill < 2 seconds

Internal Status

Motoric: Normotonus, good coordination of movementPhysiological reflex: Biceps +/+, Triceps +/+, KPR +/+Pathological reflex:Hoffman-Tromer -/-, Babinski -/-, Chaddock -/-, Neurological status

SIGNIFICANT FINDING RESUMEOnset: 3 years agoStressor: Problem with his job and his family always ask him about his job and make him feel cornered

F20.0 Paranoid schizophreniaF22.0 Delusional presistant disorder

Differential Diagnose

Axis I: F20.0 Paranoid schizophreniaAxis II: R46.8 delayed diagnoseAxis III: no diagnoseAxis IV: Problem with his job and primary support group problem ( his family always ask him about his job and make him feel cornered)Axis V: GAF 30-21Multiaxial Diagnose

HospitalizationGoal therapy is patient response with 50% of symptoms decreasedHospital treatment plans should be oriented toward practical issues of self-care, quality of life, employment, and social relationshipsTo establish an effective association between patients and community support systems

Therapy

Psychosocial TherapyFamily-Oriented TherapiesTreat patient until 50% symptom goneExplain to patients family about mental disorder. These are many factors cause the symptoms, such as biomolecules imbalance in the brain , so we need various aspects for the treatmentDont force the patient to understand the family instead vice versa Treat the patient according to the familys abilityHelp the patient when he need itEducate the family to encourage the communication and understanding

ERLodomer inj 1 amp IMDiazepam inj 1 amp IVRoom Risperidon 2 x 2mg

Therapy

Ad vitam : ad bonam Ad functionum : dubia ad malamAd sanationum : dubia ad malam PROGNOSIS

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