, November 24 2014: Monday

Monday , November 24th 2014

Supervisor : dr. Sabar P Siregar Sp.KJ

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Name Age Gender Address Occupation Marriage Status Religion Last Education

: Mr. Qoimun : 34 years old : Male : Delok Kidul 2/5 Munglid Magelang : Seller : unmarried : Islam : Elemantary School

Guardian • Name • Age • Relation

: Mr. Haryanto : 50 years old : Uncle

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Patient is brought to the hospital by her uncle due to his nephew was try to suicide three times.

He always keep his feeling to woman and he never tell her about his feeling  The patient’s father had died and his mother worked as a housekeeper, and the patient had stopped working as a trader sandals 

May 2014 (6 months before admission)

August 2014 (3 months before admission)

• The patient felt sad, guilty, and often daydream. Patient had been banging his head repeatedly against the wall. The patient began to have difficulty sleeping.

• The patient had attempted suicide by jumping from the second floor but was stopped by neighbors. Patient committed suicide because he feels worseless living his live and always feel guilty. Patient also seeing himself is a demon in the form of “genderuwo”. Patient also heard the voice repeated in his ear that is not heard by others. Patient smell the faeces but there is no faeces in the surrounding.

5 days before admission

On the day of admission

• Patient want to kill himself twice to jump into the river and with a knife. Patient feel his stomach entered the hospital and the car so that stomach ache.

• The Symptoms are worsen • The family is concerned about the patient’s condition.

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Psyciatry History Medication Trauma Patient had been banging his head repeatedly against the wall Drugs and alcohol abuse history and smoking history - Alcohol consumption (-) - Tobacco consumption (-) - Drug use (-)

1.

Prenatal and Perinatal History

2.

Early childhood phase

3.

Intermediate childhood

4.

Late childhood

5.

adulthood

Her uncle did not know about any medical condition during pre and perinatal (no valid data).

Developmental History (Gross Motoric) Ability

Result

Normal range

Elevating the head

Normal

0-3 months

Moving to supine position on its own

Normal

3-6 months

Sitting

Normal

6-9 months

Standing

Normal

9-12 months

Walking

Normal

12-24 months

Climbing up the ladder

Normal

24-36 bulan

Standing 1 foot / jump

Normal

36-48 bulan

Developmental History (Fine Motoric) Ability

Result

Normal range

Holding a pencil

Normal

3-6 months

Holding 2 objects at the same time

Normal

6-9 months

Piling 2 cubes

Normal

9-12 months

Inserting objects into container

Normal

12-18 months

Rolling a ball

Normal

18-24 months

Doodling

Normal

24-36 months

Wearing shirt

Normal

36-48 months

Ability

Result

Normal range

Oooh-aah

Normal

0-3 months

Turning toward the sound

Normal

3-5 months

High-pitched sound

Normal

3-6 months

Voice without meaning (mamama, Bababa)

Normal

6-9 months

Calling 2-3 syllables without meaning

Normal

9-12 months

Calling 3-6 words that have meaning

Normal

18-24 months

Talking at least with two words

Normal

24-36 months

Mentioning name, age, and place

Normal

36-48 months

Developmental History (Social & Personal)

Ability

Result

Normal range

Know their mother

Normal

0-3 months

Reach out

Normal

3-6 months

Clap

Normal

6-9 months

Playing peek a boo

Normal

6-9 months

Know their family

Normal

9-12 months

Appoint what he wants without crying or whining

Normal

12-18 months

Tidy up toys

Normal

24-36 months

Playing with friends, follow the rules of the game

Normal

36-48 months

Psychomotor

(NO VALID DATA) No valid data on when patient first time climbing the tree or play hide and seek games, and if patient ever involved in any kind of sports. Psychosocial (NO VALID DATA) There were no valid data on patient’s gender identification, interaction with his surrounding There were no data on when patient first entered primary school, how well patient handle separation from parents, how well he plays with new friendson first day of school Communication

(NO VALID DATA) There were no valid data regarding patient’s ability to make friends in school, and how many friends patient have during his schooling period. Emotion (NO VALID DATA) No valid data on patient adaptation under stress Cognitive (NO VALID DATA) No valid data on patient’s grades in school

Sexual

Development Sign and Activity (NO VALID DATA) No data on when patient experience wet dream, growth hair on armpits, growth pubic hair, etc. 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 on when and how patient’s relationship with different gender, if patient ever had any relationship with opposite gender. Communication

(NO VALID DATA) No valid data on how well the relathionship between patient with parents and other family. Emotion (NO VALID DATA) No data if patient ever told friend or family regarding any problems No data if patient attempted to break the rules (truant school subject, fight with friends, bullying, ect) and consuming alcohol, smoke and drugs

Physical Physically active Rule of three: 3 yrs, 3 ft, 33 lbs.

Weight gain : 4-5 lbs per year Growth : 3-4 inches per year

Physically active, can’t sit still for long Clumsy throwing balls

Cognitive Ego-centric, illogical, magical thinking

Social

Play : • Cooperative, Imaginative, may involve Explosion of vocabulary ; fantasy and imaginary learning syntax, grammar friends, takes turn in ; understood by 75 % of games people by age 3 •Develops gross and fine Poor understanding of motor skills ; social time, value, sequence of skills; experiment with events social roles ; reduces fears Vivid imaginations ; some difficulty Wants to please adults separating fantasy from reality Accurate memory, but more suggestible than

Refines complex skills : hopping, jumping, climbing, running, ride “big wheels” and tricycles Improving fine motor skills and eye-hand coordination: cut with scissors, draw shapes 3 – 3 ½ yr : most toilet trained

Primitive drawing, can’t represent themselves in drawing till age 4 Don’t realize others have different perspective Leave out important facts May misinterpret visual cues of emotions Receptive language better than expressive till age 4

Development of conscience; incorporates parental prohibitions; feels guilty when disobedient; simplistic idea of “good and bad” behavior Curious about his and other’s bodies, may masturbate

No sense of privacy Primitive, stereotypic understanding of gender roles

Emotional

Possible effects of maltreatment

Self- esteem based on what others tell him or her

Poor muscle tone, motor coordination

Increasing ability to control emotions; less emotional outbursts

Cognitive delay : inability to concentrate

Increased frustation tolerance Better delay gratification

Rudimentary sense of self Understands concepts of right and wrong Self-esteem reflects opinions of significant others

Poor pronunciation, incomplete sentences

Cannot play cooperative : lack curiosity, absent imaginative and fantasy play Social Immaturity; unable to share or negotiate with peers; overly bossy, aggressive, competitive Attachment problems : overly clingy, superficial attachments, show little distress or over-react when separated from caregiver Underweight from malnourishment : small stature Excessively fearful, anxious, night terrors Reminders of traumatic experience may trigger severe anxiety, aggression, preoccupation

Curious

Lack impulse control, little ability to delay gratification

Self-directed in many

Exaggerated response (tantrums, aggression) to even mild

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Educational History

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Elementary School 

Marriage Status

Live with his mother 

unmarried 

Social Activity Normal interaction

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Occupational History Seller

Current Situation

Religious History Moslem

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Criminal History No criminal history

Erikson’s 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

Conclusion: no clear data

Family history • He is the 1st son from 2 siblings

• His father was dead in 2013, and he live with his mother because his daughter was married

Psychosexual History • Patient psychosexual history is appropriate to his gender. He realizes that He is male and behaves according to his gender.

Socio-Economic History • Economic Scale : Poor. The patient’s father had died and his mother worked as a housekeeper, and the patient had stopped working as a trader sandals

Validity • Alloanamnesis • Autoanamnesis

: Valid Data : Valid Data

Symptom

May 2014

Role of Function

Nov 2014

Appearance

A Male, appropiate to his age, wear complete clothes, poor self grooming. State

of Consciousness

Clear Speech

- Quantity - Quality

: Decrease : Decrease

BEHAVIOUR Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Stereotypy

Mannerism Automatism Bizarre Command automatism Mutism Acathysia

Tic Somnabulism

Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

ATTITUDE Cooperative Non-cooperative

Infantile

Indiferrent

Distrust

Apathy

Labile

Tension

Rigid

Dependent

Passive negativism

Catalepsy Cerea flexibility Excitement

Emotion Mood • • • • • •

Dysphoric Elevated Euphoria Expansive Irritable Can’t be assesed

Affect • • • • • •

Appropriate Inappropriate Restrictive Blunted Flat Labile

Disturbance of Perception Hallucination • Auditory (+) heard the voice

repeated in his ear • Visual (+) seeing himself is a demon in the form of “genderuwo” • Olfactory (+) smell the faeces but there is no faeces in the surrounding

• • • •

Gustatory (-) Tactile (-) Somatic (-) Undeferrentiated (-)

Depersonalisation (-)

Illusion • • • • • • •

Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Undeferrentiated (-)

Derealisation (-)

Thought Progression Quantity • • • • •

Logorrhea Blocking Remming Mutisme Talkative

Quality • • • • • • • • • • • • • • •

Irrelevan answer Incoherence Flight of idea Confabulation Poverty of speech Slow speech Loosening of association Neologisme Circumtansiality Tangential Verbigrasi Perseverasi Sound association Word salad Echolalia

Content of thought 

Idea of Reference

 Delusion of Grandiose

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Preocupation

 Delusion of Control

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Obsession

 Delusion of Influence

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Phobia

 Delusion of Passivity

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Delusion of Persecution

 Delusion of Perception

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Delusion of Reference

 Thought of Echo

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Delusion of Envious

 Thought Insertion

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Delusion of Hipochondry

 Thought of withdrawal

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Delusion of magic-mystic

 Thought Broadcasting

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Fantasy

 Can’t be assesed

Form of Thought • Realistic • Non Realistic • Dereistic • Autistic

Sensorium and Cognition      

Level of education : Low General knowledge : Low Orientation of time/ place/people/situation : Good/good/good/good Working/short/long memory: Poor/good/good Writing and reading skills : good Ability to self care : poor

Impulse Control When Examined • Self control : Average. • Patient response to examiners question: Poor.

Insight • Impaired insight (patient do not know he is mentally ill) • Intelectual Insight • True Insight

Physical examination  Conciousness  Vital

: composmentis

sign:

- Blood pressure - Pulse rate - Temperature - RR

: 140/100 mmHg : 84 x/min : 36,2 : 20 x/min

•Skin •Head • Eye • Nose • Ear • Mouth •Neck •Lungs

: rash(-), petechiae (-)

: conjunctival pallor (-), yellowish sclera (-) : discharge(-), nasal flare (-) : discharge(-) : within normal limit : lymphnodes within normal limit : symmetrical, retraction(-), vesicular (+/+), abnormal lung sounds (-/-) •Heart : S1, S2 regular, murmur(-), cardiomegaly (-) •Abdomen : Supple, tympany (+), Distention (-), Hepatomegaly (-), Splenomeogaly (-)

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Motorik : Normotonus, good coordination of movement

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Meningeal sign : negative

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Physiologic reflex : +/+

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Patologic reflex : -/-

: 6 months ago

Onset Symptoms

The patient felt sad, guilty, and often daydream. Patient had been banging his head repeatedly against the wall. The patient had attempted suicide 3 times because he feels worseless living his live and always feel guilty

Mental status Mood: dysphoric Affect: appropriate, Disturbance of perception: hallucination of auditory(+), visual (+), olfactory (+) Tought progression: - Quality: Poverty of speech, slow speech - Quantity: Remming Content of tought : Delusion of hypocondric, delusion of magic-mystic Form of tought: Non realistic

Impairment

•Rarely to take a bath •Lazy to work •Limited social interaction •Tentamen suicide

• F32.3 Psychotic features associated with severe

depression • F25.1 Schizoaffective Depression Type

Axis I : F32.3 Psychotic features associated with severe depression

Axis II : Z.03.2 none Axis III : none Axis IV : He always keep his feeling to woman and he never tell her

about his feeling, The patient’s father had died and his mother worked as a housekeeper, and the patient had stopped working as a trader sandals Axis V : GAF admission 20 – 11

1. Problem about patient’s life (social) He always keep his feeling to woman and he never tell her about his feeling, Economy : poor, The patient’s father had died and his mother worked as a housekeeper, and the patient had stopped working as a trader sandals 2. Problem about patient’s biological state (biology) There were abnormality imbalance neurotransmitter, hyperactivity of serotonin and dopamine. 3. Problem about patient’s mental state (psychology) Auditory , Visual, Olfactory hallucination , Dellusion of Magic-Mystic

INPATIENT (HOSPITALIZATION) • Tentamen Suicide • Auditory , Visual, Olfactory hallucination • Waham magic-mystic

Emergency department

Inj. Diazepam 1 ampule IV Inj. Haloperidol 1 ampule IM

Target therapy : 50% decrease of symptoms Maintenance Amitriptylin tab 3 x 25 mg/ day Inj. Haloperidol 1 ampule IM

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Target therapy : - 100% remission of symptom Inpatient management - Continue the pharmacotherapy: Amitriptylin tab 150 mg/day Inj. Haloperidol 1 ampule IM - 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 her spare time) Outpatient management - Pharmacotherapy

Continue the medication, control to psychiatric Rehabilitation : - Help patient to interact normally with her family, friends, and neighbor - Do some activities that can keep patient occupied - Family education