A. PATIENTSS IDENTITY Name : Mrs. S Age : 26 years old Gender : Female Address : seneng 03/01 banyurojo mertoyudan magelang Occupation : Unemployed Marriage status : Single Last education : Senior high school GUARDIANS IDENTITY Name : Mr. S Age : 72 years old Relation : Father B. CAUSES BROUGHT THE PATIENT TO THE HOSPITAL Patient believe that she will be die and unable to communicate well with others. C. PRESENTING ILLNESS A woman taken to hospital by her father. According to her father, since 4 days ago his daughter starting to talk and laugh alone. Beside that her father said that his daughter suddenly faint twice when they walk. The patient difficult to sleep, felt that everybody hate her, everybody talk about her, felt difficult to breath and will be death. Her father also said that his daughter easily becomes angry. The patient said that she heard the voices of God and prophet that told her she will be die. Her father said that in august 2013 his daughter was taken to RSJ Soerojo because of the same reason and she got discharge from hospital in September 2013. D. HISTORY OF PRESENT ILLNESS Psychiatry history 2005 = The patient diagnosed suffer from schizophrenia 2010 = The patient diagnosed suffer from schizophrenia 2012 = The patient diagnosed suffer from schizoaffective General medical history None Drugs and alcohol abuse history and smoking history Alcohol consumption (-) Tobacco consumption (-) drug use (-) E. PERSONAL HISTORY 1. Early Childhood Phase (0-3 Years Old) Psychomotoric (NO VALI D DATA) There were no valid data on patients growth and development such as: first time lifting the head (3-6 months) rolling over (3-6 months) Sitting (6-9 months) Crawling (6-9 months) Standing (6-9 months) walking-running (9-12 months) holding objects in her hand(3-6 months) putting everything in her mouth(3-6 months) Psychosocial (NO VALI D DATA) There were no valid data on which age patient: started smiling when seeing another face (3-6 months) startled by noises(3-6 months) when the patient first laugh or squirm when asked to play, nor playing claps with others (6-9 months) Communication (NO VALI D DATA) There were no valid data on when patient started saying words 1 year like bapak or ibu. (6-9 months)
Emotion (NO VALI D DATA) 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 (NO VALI D DATA) 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. 2. Intermediate Childhood (3-11 Years Old) Psychomotor (NO VALI D DATA) No valid data on when patients first time climbing the tree or hide and seek, if patient ever involved in any kind of sports. Psychosocial (NO VALI D DATA) There were no valid data on patients gender identification, interaction with him surroundings 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 school Communication (NO VALI D 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 VALI D DATA) No valid data on patients adaptation under stress Cognitive (No VALI D DATA) No valid data on patients grades in school
3. Late Childhood & Teenage Phase Sexual development signs & activity (NO VALI D DATA) No data on when patient experience menarche, hair on armpits or , etc Psychomotor (NO VALI D DATA) No data if patient had any favourite hobbies or games, if patient involved in any kind of sports. Psychosocial (NO VALI D DATA) No data if while growing up did she make many friends, how well patient make any friends and how much friends. No valid data on when and how patients relationship with different gender, if patient ever had any relationship with the opposite gender. Emotional (VALI D DATA) Patient seldom told friends or family regarding any problems. No data if patient attempted to break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugs Communication (NO VALI D DATA) Patient has a good relationship with parents and other family. 4. Adulthood Educational History Senior High School Occupational history None Marital Status unmarried Criminal History None Social Activity Patient seldom to get interaction with her neighbour Current Situation Lives with his parents Religious history Pray routinely before illness
F. Eriksons 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: She is a quite person and seldom to tell a friend or family about her problems so she have a social relationships problems. G. History Family History The patient is the last child from 4 siblings and she has two brothers and one sister. All her siblings already married and she is the only one who havent. Psychosexual history Patient psychosexual history is appropriate of her gender. She realize that she is a female and behaves according to her gender. Genogram Socio-economic history Economic scale : low Validity Alloanamnesis : valid Autoanamnesis : valid I. PROGRESSION OF ILNESS J. MENTAL STATUS Appearance : A woman, appropriate according to age, wear complete clothes, and good self grooming. State of Consciousness: Clear Speech: Quantity : increased Quality : decreased Behaviour : Psychomotor agitation Aggresive Attitude: Non-cooperative Infantile Labile Emotion Mood: Irritable Afect: Appropriate Disturbance of perception The patient said that she heard the voices of GOD and prophet it means she has a hallucination of auditory. Thought of progression Quantity : Talk active Quality : Loosening of association Content of thought : Delusion of reference Thought of progression : Non-realistic Sensorium and cognition Level of education : enough General knowledge : undeferrentiated Orientation of time/place/people/situation : good Working/short/long memory : cant be assessed Writing and reading skills : cant be assessed Visuospatial : cant be assessed Abstract thinking : cant be assessed Ability to self care : decrease Note: The patients condition is non-cooperative. The patient easily to get angry when someone asked her. So some data cant be assessed. Impulse control when examined Self control : bad Patient response to examiners question : bad Insight : Intelectual Insight K. INTERNAL STATUS Conciousnes : compos mentis Vital sign: Blood pressure : 140/80 mmHg Pulse rate : 104 x/mnt Temperature : afebris RR : 24 x/mnt Head : normocephali Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore Neck : normal, no rigidity, no palpable lymph nodes Thorax : - Cor : S1,2 Sound and normal - Lung : vesicular sound, wheezing -/-, ronchi-/- Abdomen : Pain (-) , normal peristaltic, tympany sound Extremity : Warm acral, capp refill <2 L. NEUROLOGICAL STATUS Motorik : Normotonus, good coordination of movement Meningeal sign : negative Physiologic reflect : +/+ Patologic reflect : -/- M. SIGNIFICANT FINDING RESUME Onset: 2 months ago Stressor: problem with husbands family and financial problem Symptoms o Anger tantrums, Agitated and sensitive o Hearing voices o Felt everybody hate and talk about her Disability o Unemployed o Social withdrawal Mental Status o Behaviour : Agressive, Psychomotor agitation, Cataplexy o Attitude : Non cooperative o Mood : Irritable o Affect : Aproppriate o Thought progression : lossening of association o Form of thought : Non-realistic o Insight : intellectual insight N. DIFFERENTIAL DIAGNOSE F20.0 Paranoid schizophrenia F20.2 Schizoaphrenia catatonic type F31.0 Bipolar affective disorder, current episode of hypomania O. MULTIAXIAL DIAGNOSE Axis I : F 20.0 Paranoid Schizophrenia Axis II : R 61.0 Mixed personality disorder Axis III : no diagnose Axis IV : Social environment problem Axis V : GAF admission 20-11 GAF 1 year recent 40-31 P. PLANNING MANAGEMENT 1. Hospitalization: Fixation and pharmacotherapy. a. Purpose of hospitalization is to decrease the aggressive symptoms, so patient can handle herself, and not threatening people around him. b. Hospital treatment plans should be oriented toward practical issues of quality of life, role function and social relationships. c. To establish an effective association between patients and community support systems. d. Pharmacotherapy Emergency Room : Inj Diazepam mg IV & Inj Haloperidol 5mg IM Routine therapy : Antipsikotik tipikal & Haloperidol 2 x 5mg 2. Psycho-education after medication Educate the patient and family after medication: Explain to patients family about mental disorder. There are many factors cause the symptoms, such as biommoleculer imbalance in the brain, so we need various aspects for the treatment. Dont force the patient to understand the family instead vice versa. Treat the patient according to the familys ability, dont demand the patient more nor less. Help the patient when she needs it. Education of the family to encourage communication and understanding.
Question: What should we do or explain if the patients ask about why the drugs should be consume routinely? Answer: The drugs is for curing the sickness, but if the patient already cure by the medicine the drugs should be consume routinely to make the patient still stable and not relaps. But the most important the drugs keep the pysche health not being regression and still health (not frequently relaps).