Thursday, 20th September 2012 Supervisor : dr Sabar P Siregar Sp.

Kj

Sufferers Identity
Name Age Gender Address Occupation Marriage status Religion Last education Alloanamnesis Name Age Relation : Mr.A : 25 years old : Male : Banjarnegara : Unemployed : Single : Muslem : Junior High School : Mrs. M : 45 years old : Patients Mother

Chief complaint

Anger tantrums

Presenting illness
1 year ago
Did not take medications Talks to himself & laughs by himself. Agitated & sensitive, short tempered Anger tantrums (no reason) : throwing furniture and assaulting family members. Assaults neighbours Hearing voices controlling him Sees supernatural being Patient felt being pushed by non-existent person till patient fell down.

Today
Brought to hospital today because just found financial support

HISTORY OF PRESENT ILLNESS

Psychiatry history
Social withdrawal since 8.5 years ago. Hallucinations, Delusions, disorientation since 8 years ago. Hospitalization 10 x in RS Banyumas. Medications not routinely taken Stressor unclear General medical history Drugs and alcohol abuse history and smoking history Alcohol consumption (-) Tobacco consumption (+) Drugs abuse (-)

Head injury (+) 8 yrs ago Convulsion (-) Asthma (-) Allergy (-)

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.

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.

 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.

Intermediate Childhood (3-11 years old)

Psychomotor No valid data on when patients first time riding a tricycle or bicycle, if patient ever 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 friends on 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 of bedwetting were not known. Cognitive No valid data on patients achievement in school, how well patient;s reading ability and grades.

Late Childhood & Teenage Phase

Sexual development signs & activity No valid data on when patient experience wet dream, hair on armpits and pubis, 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.

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.

Psychosexual history
Patient psychosexual history is appropriate of his gender and attracted to female Had a girlfriend but broke off 2 years ago.

Genogram

Socioeconomic history

Economically supported by father and mother. Socio-economic status : Low

Validity

Alloanamnesis : valid Autoanamnesis : not valid

Progression of Ilness
symptom

8 yrs ago

5 years ago

1 year ago till now

Role function

Mental State
Appearance : Male, 25 years old, appropriate for age, satisfactory grooming
State of Consciousness

Clouded
Speech:

Quantity: increased
Quality: poor

Behaviour
Hypoactive Hyperactive Normoactive Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

ATTITUDE
Non-cooperative Cooperative Indiferrent Apathy Tension Dependent Active Passive Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility Excitement

Emotion
Mood
Euthymic Dysphoric Euphoria Elevated Expansive Irritable Cant be assesed

Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile

Disturbance of perception
Hallucination
auditory Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cannot be assessed Illusion Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cannot be assessed

Depersonalisation (-)

Derealisation (-)

Thinking thought progression

Quantity
Logorrhea
Blocking Remming Mutisme Talk active

Quality
Irrelevant answer Coherence Confabulation Poverty of speech Flight of idea Sound association Loosening of association Incoherence Word salad Neologisme Circumstantiality Tangentiallity Verbigration Perseveration Echolalia

 Idea of Reference Preoccupation Obsession Phobia

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/withdrawal

Delusion of pursue
Delusion of suspicious Delusion of envious Delusion of hipochondria

Thought of broadcasting

Thought process
Form of Thought

Realistic Non Realistic Dereistic Autistic

Sensorium and Cognition

Level of education : enough General knowledge : Cannot be assessed Orientation of time/place/people/situation: poor/poor/poor/poor Memory : cannot be assessed Writing & reading : cannot be assessed Visuospatial : cannot be assessed Abstract thinking : cannot be assessed Ability to self care : cannot be assessed

Impulse control when examined

Poor

Insight

Impaired insight Intellectual Insight True Insight

Internal Status
Conciousnes: compos mentis Vital sign:
Blood pressure Pulse rate Temperature RR : 120/80 mmHg : 82 x/mnt : 36.6 C : 20 x/mnt

 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

Neurological status
Motoric: normotonus, good coordination of movement Physiological reflex: +/+ Pathological reflex: -/-

SIGNIFICANT FINDING RESUME

Onset: 1 year ago Stressor: Unknown

Symptoms

Disability

Mental Status

Orientation : Poor

Anger tantrums, Agitated and sensitive

Talk and laugh by himself

Consciousness : Clouded

- Unemployed - Socially
aggressive - Day dream during free time

Behaviour : Hyperactive, Psychomotor agitation Attitude : Non cooperative Mood : Irritable ; Affect : labile Thought progression : logorrhea, tangentiality Form of thought : Autistic Insight : Impaired

Hearing voices, sees supernatural being Assault neighbours

- Bad Self grooming

Differential Diagnose
F 20.0. Paranoid Schizophrenia F20.2 Catatonic Schizophrenia F 30.2 Mania with Psychotic Symptoms

Multiaxial Diagnose
Axis I Axis II Axis III Axis IV Axis V : F 20.0 Paranoid Schizophrenia : Z03.2 No diagnosis : None : unclear stressor : GAF admission 20-11 The highest GAF in a year : 20-11

Therapy
Hospitalization
To establish an effective association between patients and community support systems Hospital treatment plans should be oriented toward practical issues of self-care, quality of life, employment, and social relationships

 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

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

Thank you