Monday , November 24th 2014

Supervisor :
dr. Sabar P Siregar Sp.KJ
• Name : Mr. Qoimun
• Age : 34 years old
• Gender : Male
• Address : Delok Kidul 2/5 Munglid Magelang
• Occupation : Seller
• Marriage Status : unmarried
• Religion : Islam
• Last Education : Elemantary School
Guardian
• Name : Mr. Haryanto
• Age : 50 years old
• Relation : Uncle
 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 • The patient felt sad, guilty, and often
(6 months daydream. Patient had been banging his
before head repeatedly against the wall. The
admission) patient began to have difficulty sleeping.

• The patient had attempted suicide by jumping from the

August second floor but was stopped by neighbors. Patient
2014 (3 committed suicide because he feels worseless living his
live and always feel guilty. Patient also seeing himself
months is a demon in the form of “genderuwo”. Patient also
before heard the voice repeated in his ear that is not heard by
admission) others. Patient smell the faeces but there is no faeces
in the surrounding.
 5 days • Patient want to kill himself twice to
jump into the river and with a knife.
before Patient feel his stomach entered the
hospital and the car so that stomach
admission ache.

On the • The Symptoms are worsen

day of • The family is concerned about the
patient’s condition.
admission
 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 Normal 3-6 months

on its own
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, Normal 6-9 months

Bababa)
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 Normal 12-18 months
whining
Tidy up toys Normal 24-36 months
Playing with friends, follow the rules of Normal 36-48 months
the game
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 Social
Ego-centric, illogical, Play :
magical thinking • 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 Primitive drawing, Development of
skills : hopping, can’t represent conscience;
jumping, climbing, themselves in incorporates
running, ride “big drawing till age 4 parental
wheels” and tricycles prohibitions; feels
Don’t realize others guilty when
Improving fine have different disobedient;
motor skills and perspective simplistic idea of
eye-hand “good and bad”
coordination: cut Leave out important behavior
with scissors, draw facts
shapes Curious about his
May misinterpret and other’s bodies,
3 – 3 ½ yr : most visual cues of may masturbate
toilet trained emotions
No sense of privacy
Receptive language
better than Primitive, stereotypic
expressive till age 4 understanding of
gender roles
Emotional Possible effects of maltreatment
Self- esteem based on Poor muscle tone, motor coordination
what others tell him or
her Poor pronunciation, incomplete sentences

Increasing ability to Cognitive delay : inability to concentrate

control emotions; less
emotional outbursts Cannot play cooperative : lack curiosity, absent imaginative
and fantasy play
Increased frustation
tolerance Social Immaturity; unable to share or negotiate with peers;
overly bossy, aggressive, competitive
Better delay gratification
Attachment problems : overly clingy, superficial attachments,
Rudimentary sense of show little distress or over-react when separated from
self caregiver

Understands concepts of Underweight from malnourishment : small stature

right and wrong
Excessively fearful, anxious, night terrors
Self-esteem reflects
opinions of significant Reminders of traumatic experience may trigger severe anxiety,
others aggression, preoccupation

Curious Lack impulse control, little ability to delay gratification

Self-directed in many Exaggerated response (tantrums, aggression) to even mild

 Educational History  Current Situation
Elementary School Live with his mother
 Marriage Status  Religious History
unmarried Moslem
 Social Activity  Criminal History
Normal interaction No criminal history
 Occupational History
Seller
 Erikson’s Stages of Psychosocial Development

Stage Basic Conflict Important Events

Infancy Trust vs mistrust Feeding
(birth to 18 months)
Early childhood Autonomy vs shame and doubt Toilet training
(2-3 years)
Preschool Initiative vs guilt Exploration
(3-5 years)
School age Industry vs inferiority School
(6-11 years)
Adolescence Identity vs role confusion Social relationships
(12-18 years)
Young Adulthood Intimacy vs isolation Relationship
(19-40 years)
Middle adulthood Generativity vs stagnation Work and parenthood
(40-65 years)
Maturity Ego integrity vs despair Reflection on life
(65- death)

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 : Valid Data
• Autoanamnesis : Valid Data
 Symptom

Nov
May 2014
2014

Role of Function
Appearance
A Male, appropiate to his age, wear complete
clothes, poor self grooming.
State of Consciousness
Clear
Speech
- Quantity : Decrease
- Quality : Decrease
 BEHAVIOUR
Mannerism
Hypoactive Psychomotor
Automatism agitation
Hyperactive
Bizarre Compulsive
Echopraxia
Command Ataxia
Catatonia
automatism
Active negativism Mimicry
Mutism
Cataplexy Aggresive
Acathysia
Stereotypy Impulsive
Tic
Abulia
Somnabulism
 ATTITUDE
Cooperative
Passive
Non-cooperative Infantile
negativism
Indiferrent Distrust
Catalepsy
Apathy Labile
Cerea flexibility
Tension Rigid
Excitement
Dependent
 Emotion

Mood Affect
• Appropriate
• Dysphoric • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
• Can’t be assesed
 Disturbance of Perception

Hallucination Illusion
• Auditory (+) heard the voice
repeated in his ear
• Auditory (-)
• Visual (+) seeing himself is a • Visual (-)
demon in the form of • Olfactory (-)
“genderuwo”
• Gustatory (-)
• Olfactory (+) smell the faeces
but there is no faeces in the • Tactile (-)
surrounding • Somatic (-)
• Gustatory (-)
• Tactile (-) • Undeferrentiated (-)
• Somatic (-)
• Undeferrentiated (-)

Derealisation (-)
Depersonalisation (-)
 Thought Progression
Quantity Quality
• Irrelevan answer
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Confabulation
• Mutisme • Poverty of speech
• Slow speech
• Talkative
• Loosening of association
• Neologisme
• Circumtansiality
• Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
 Content of thought
 Idea of Reference  Delusion of Grandiose

 Preocupation  Delusion of Control

 Obsession  Delusion of Influence

 Phobia  Delusion of Passivity

 Delusion of Persecution  Delusion of Perception

 Delusion of Reference  Thought of Echo

 Delusion of Envious  Thought Insertion

 Delusion of Hipochondry  Thought of withdrawal

 Delusion of magic-mystic  Thought Broadcasting

 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 : composmentis

 Vital sign:
- Blood pressure : 140/100 mmHg
- Pulse rate : 84 x/min
- Temperature : 36,2
- RR : 20 x/min
•Skin : rash(-), petechiae (-)
•Head
• Eye : conjunctival pallor (-), yellowish sclera (-)
• Nose : discharge(-), nasal flare (-)
• Ear : discharge(-)
• Mouth: within normal limit
•Neck : lymphnodes within normal limit
•Lungs : symmetrical, retraction(-), vesicular (+/+),
abnormal lung sounds (-/-)
•Heart : S1, S2 regular, murmur(-), cardiomegaly
(-)
•Abdomen : Supple, tympany (+), Distention (-),
Hepatomegaly (-), Splenomeogaly (-)
 Motorik : Normotonus, good coordination of
movement
 Meningeal sign : negative
 Physiologic reflex : +/+
 Patologic reflex : -/-
Onset : 6 months ago

Symptoms Mental status Impairment

•Rarely to take a
The patient felt sad, Mood: dysphoric
guilty, and often Affect: appropriate, bath
daydream. Patient had Disturbance of perception: •Lazy to work
been banging his head hallucination of
•Limited social
repeatedly against the auditory(+), visual (+),
wall. olfactory (+) interaction
The patient had Tought progression: •Tentamen suicide
- Quality: Poverty of
attempted suicide 3 speech, slow speech
times because he feels
- Quantity: Remming
worseless living his live
Content of tought :
and always feel guilty Delusion of
hypocondric, delusion
of magic-mystic
Form of tought: Non
realistic
• 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
 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