Tuesday , December 11th, 2012

Supervisor : dr Sabar P Siregar Sp.Kj

PATIENT’S IDENTITY Name : Miss KAge : 40 years oldGender : FemaleAddress : TemanggungOccupation : UnemployeeMarital status : SingleLast education : no education

AlloanamnesisName : Mrs. M Age : 31 years oldRelation : Sister

ANAMNESISChief complaint : run amuck PRESENT HISTORY (alloanamnesis)

Since her mom died 6 years ago, the patient begin: run amuck, take a walk and back home in the evening, throw a stone to the neighbour’s home, hit anyone in front of her or pull of hair, sometimes walk nakedly in the road, smile-laugh to herself, and get over eating. Her sister unable to take care of patient at home.

The patient also doesn’t want to work such as clean home and wash plates or glass like before her mom died. When reminded to eat or take a bath, sometimes she get angry immediately.

PAST ILLNESS HISTORY Psychiatry history General medical

historyDrugs and alcohol abuse history and smoking history

Patient borned with deaf mute. She is a irritable woman, often angry since as a children. She also smile-laugh to herself. Her parents never complain to doctor about patient’s condition. At home, she still able to do a little of home tasks like washing plate and cleaning the house.

Hypertension (-)Head injury (-) Asthma (-)Febrile seizure (-)Deaf-mute (+) since patient borned and wasn’t be examined to doctor.

Alcohol consumption(-)Tobacco consumption (-) Drug use (-)

History of Personal Life Prenatal and Perinatal HistoryPrenatal and Perinatal History

There were no valid data about her mother condition when she’s pregnant and the patient condition when delivered.

Early Childhood Phase (0-3 Years Old)Early Childhood Phase (0-3 Years Old)Psychomotoric

There were no valid data about patient’s growth and development.Psychosocial

There were no valid data about patient started smiling when seeing another face.

Emotion There were no valid data about patient 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 understanding simple orders.

Intermediate Childhood (3-11 y.o)Intermediate Childhood (3-11 y.o)Psychomotor No valid data .Psychosocial Patient’s gender identification is normalCommunication Patient had no friend and unable to socialized well.Emotional Patient was iritable.Cognitive No valid data

Late Childhood & Teenage PhaseLate Childhood & Teenage PhaseSexual development signs & activity

No valid dataPsychomotor

No valid dataPsychosocial

Patient had no friend and unable to socialized well.Emotional Patient is iritable.

AdulthoodAdulthoodEducational and Occupational History : No school and no jobMarital status : UnmarriedLegal History : Never been arrested or caught by police.Social Activity : No social activity.Current Situation : Living with her sister, the sister’s husband.Religious History : Nothing

No another one of family that has a psychiatric disorder.

Family History

Psychosexual historyNo valid data.Socio-economic history : Economic scale: low ValidityAlloanamnesis : validAutoanamnesis: invalid

Genogram

Progression of Ilness

Symptoms

born 2007 2012

Role of function

III. Mental State Appearance :

Adult woman, appropriate according to age, dressed appropriately

State of Consciousness

Can’t be assessed Speech:

◦ Quantity : Decreased◦ Quality : Decreased

BehaviourNormoactiveHypoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStereotypyMannerismAutomatism

Command automatismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresive ImpulsiveAbulia

ATTITUDE Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Active Passive

InfantileDistrustLabileRigidPassive negativismStereotypyCatalepsyCerea flexibility

EmotionMoodDysphoricEuphoriaElevatedExpansiveIrritable Can’t be assesed

AffectAppropriateInappropriateRestrictiveBluntedFlatLabile

Disturbance of perceptionHallucinationAuditoryVisual Olfactory Gustatory Tactile Somatic

Derealisasi

IllusionAuditory Visual Olfactory Gustatory Tactile Somatic

DepersonalisasiCan’t be assesed

Thinkingthought progression

Quantity Logorrhea Blocking Remming Mutisme Talk active

Quality Relevan answer Irrelevan answer Incoherence Flight of idea Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality Tangential Verbigrasi Perseverasi Sound association Word salad EcholaliaCan’t be assesed

Thought Processcontent of thought Idea of reference

Preokupasi

Obsesi

Fobia

Delution of persecution

Delution of Reference

Delution of envious

Delution of hipokondri

Delution of Grandeous

Delusion of magic-mistic

Delusion of control

Delusion of influence

Delusion of passivity

Delusion of perception

Thought of echo

Thought of insertion/withdrawal

Thought of broadcastingCan’t be assesed

Thought formRealisticNon RealisticDereisticAutistic

Can’t be assesed

SENSORIUM and cognition Level of education : never get education General knowledge : can’t be assessed Orientation of time : can’t be assessed

place : can’t be assessed people : can’t be assessed

situation : can’t be assessed Working/short/long memory : can’t be assessed Writing and reading skills : can’t be assessed Visuospatial : can’t be assessed Abstract thinking : not evaluated Ability to self care : bad

Impulse control when examined : Self control : enough Patient response to examiners question: no response

Insight Impaired insight Intelectual Insight True InsightCan’t be assessed

IV. PHYSICAL EXAMINATIONConciousness : compos mentisVital sign:

Blood pressure : 140/90 mmHgTemperature : afebris

Head : normocephali Eyes : anemic conjungtiva -/-, icterik sclera

-/-, pupil isocore Neck : normal, no rigidity, no palpable

lymphnode Thorax:

Chor : S1 and S2 Sound and normal

Lung : vesicular sound, wheezing -/-, ronchi-/- Abdomen : Pain - , peristaltic normal, thympany sound Extremity : Warm acral, capp refill <2”

SIGNIFICANT FINDING RESUMEOnset Mental Status Impairment

Since 5 years ago (1 year after her mother died), the patient begin :run amuck, take a walk and back home in the evening, throw a stone to the neighbour’s home, hit anyone in front of her or pull of hair, sometimes walk nakedly in the road, smile-laugh to herself, and get over eating.

Stereotypi behaviorInfantile attitudeRestrictive affect

Dellusion and halusination can’t be assessed.

Role function: inability to work.

Spare time: take a walk

Psychosocial : bad socialization

Ability to self care : enough grooming

Differential Diagnose F20.0 Paranoid Schizophrenia

F20.2 Cathatonic Schizophrenia F73 Extreme Mental Retardation F78 Other Mental Retardation F84.4 Over Activity Disorder related with Mental

Retardation and Stereotypic Movement

VII. DIAGNOSTIC FORMULATION

Axis I : F20.0 Cathatonic SchizophreniaAxis II : F73 Extreme Mental RetardationAxis III : Deaf-mute (congenital disorder) Axis IV : Her mother died five years ago, deaf- muteAxis V : GAF 20-11

Therapy PlanningHospitalized, because the sister unable to take care of

patient at home and because the patient disturb other people and environment.

MedicationER : Lodomer 5mg Inj 1 Amp (IM) Room therapy:Haloperidol

Psychososial therapy

Mental Retardation treatment :Medical care : comphrehensive management plan from

multiple disciplines including special educators, language therapists, behavioral therapists, occupational therapists (improve physical activity and acquire skills for living), and community service (Panti Tuna Rungu).

Regular physical activity, because obesity is more prevalence in those with MR

Family educationExplain to his family about this patient mental disorderDescribes steps of treatmentFamily must keep in touch with patient intensively, so the

patient will not feel lonely.

Ad vitam : Ad BonamAd functionum : Dubia ad malamAd sanationum : Ad Malam