Thursday , November 20th 2014

Supervisor:
dr Sabar P Siregar Sp.KJ
• Name :
• Age :
• Gender :
• Address :
• Occupation :
• Marriage Status :
• Religion :
• Last Education :
Guardian
• Name :
• Age :
• Relation :
 Patient is brought to the hospital by ... due to
...
Time (onset) Time (onset)

Role function, Social function Role function, Social function

Sparetime Management, Sparetime Management, Self
Self grooming (sebutkan grooming (sebutkan
symptom dan hendaya yang symptom dan hendaya yang
ada) ada)
Day of admission

-Symptoms are worsen

-The family is
concerned about the
patient’s condition
 Psyciatry History

 Medication

 Trauma

 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
 .
 Ability Result Normal range

Elevating the head Normal 0-3 months

Moving to supine Normal 3-6 months

position 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

 Ability Result Normal range
Holding a pencil Normal 3-6 months
Holding 2 objects at the same Normal 6-9 months
time
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

 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 she wants without Normal 12-18 months
crying or whining
Tidy up toys Normal 24-36 months
Playing with friends, follow the Normal 36-48 months
rules of 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 she 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 her 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 favorite 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 relationship 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
Newborn: rough, random,
uncoordinated, reflexive movement
3 mo: head at 90 degree angle, uses
arms to prop; visually track through
midline
5 mo: purposeful grasp; roll over;
head lag disappears; reaches for
objects; transfer objects from hand
to hand; plays with feet; exercises
body by stretching, moving; touch
genitals, rock on stomach for
pleasure
7 mo: sits in “tripod”; push head and
torso up off the floor; support weight
on legs; “raking” with hands
9 mo: gets to and from sitting;
crawls, pulls to standing; stooping
and recovering; fingerthumb
opposition; eyehand coordination,
but no hand preference
12 mo: walking
15 mo: more complex motor skills
2 yrs: learns to climb up stairs first,
then down
Cognitive Social
Sensori-motor: physically explores Attachment: baby settles when
environment to learn about it; parent comforts; toddler seeks
repeats movements to master comfort from parent, safe-base
them, which also stimulates brain exploration
cell development 5 mo: responsive to social
4-5 mo: coos, curious and stimuli; facial expressions of
interested in environment emotion
6 mo: babbles and imitates sounds 9 mo: socially interactive; plays
9 mo: discriminates between games (i.e., pattycake)
parents and others; trial and error With caretakers
problem solving 11 mo: stranger anxiety;
12 mo: beginning of symbolic separation anxiety; solitary play
thinking; points to pictures in 2 yr: imitation, parallel and
books in response to verbal cue; symbolic, play
object permanence; some may use
single words; receptive language
more advanced than expressive
language
15 mo: learns through imitating
complex behaviors; knows objects
are used for specific purposes
2 yrs: 2 word phrases; uses more
complex toys and understands
sequence of putting toys, puzzles
together
Emotional
Birth-1 yr: learns fundamental trust
in self, caretakers, environment
1-3 yr: mastery of body and rudimentary mastery of
environment (can get other’s to take care of him)
12-18 mo: “terrible twos” may begin; willful,
stubborn, tantrums
18-36 mo: feel pride when they are “good” and
embarrassment when they are “bad”
18-36 mo: Can recognize distress
in others – beginning of empathy
18-36 mo: are emotionally attached to toys or objects
for security
Possible effects of maltreatment
Chronic malnutrition: growth retardation,brain
damage, possibly mental retardation
Head injury and shaking: skull fracture, mental
retardation, cerebral palsy,paralysis, coma, death,
blindness,deafness
Internal organ injuries
Chronic illness from medical neglect
Delays in gross and fine motor skills, poor muscle tone
Language and speech delays; may not use language to
communicate
Insecure or disorganized attachment:
overly clingy, lack of discrimination of
significant people, can’t use parent as
source of comfort
Passive, withdrawn, apathetic,
unresponsive to others
“Frozen watchfulness”, fearful, anxious, depressed
Feel they are “bad”
Immature play – cannot be involved in reciprocal,
interactive play
 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
Refines complex skills: hopping,
jumping, climbing, running, ride
“bigwheels” and tricycles
Improving fine motor skills and eye-
hand coordination: cut with scissors,
draw shapes
3– 3,5 yr: most toilet trained
Cognitive
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, can’t
represent themselves in drawing till age
4 “good and bad” behavior
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
Social
Play:
Cooperative,imaginative, may involve
fantasy and imaginary friends, takes
turns in games
Develops gross and fine motor skills;
social skills;
experiment with social roles;reduces
fears
Wants to please adults
Development of conscience:
Incorporates parental prohibitions; feels
guilty when disobedient; simplistic idea
of
Curious about his and other’s bodies,
may masturbate
No sense of privacy
Primitive, stereotypic
understanding of gender roles
Emotional
Self-esteem based on what others tell him or her
Increasing ability to control emotions; less
emotional outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right and wrong
Self-esteem reflects opinions of significant others
Curious
Self-directed in many activities
Possible effects of maltreatment
Poor muscle tone, motor coordination
Poor pronunciation, incomplete sentences
Cognitive delays; inability to concentrate
Cannot play cooperatively; 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
Lack impulse control, little ability to delay gratification
Exaggerated response (tantrums, aggression) to even mild
stressors
Poor self esteem, confidence; absence of initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses
Eneuresis, encopresis, self stimulating behavior –rocking,
head-banging
Physical
Slow, steady growth: 3 -4 inches per
year
Use physical activities
to develop gross and fine motor skills
Motor & perceptual
motor skills better integrated
10-12 yr: puberty
begins for some children
Cognitive
Use language as acommunication tool
Perspective taking:
5-8 yr: can recognize others’
perspectives, can’t assume the role of
the other
8–10 yr: recognize difference between
behavior and intent; age
10-11 yr: can accurately
recognize and consider
others’ viewpoints
Concrete operations:
Accurate perception of
events; rational, logical
thought; concrete thinking; reflect upon
self and attributes; understands
concepts of space, time, dimension
Can remember events
from months, or years
earlier
More effective coping skills
Understands how his
behavior affects others
Social
Friendships are situation
specific
Understands concepts
of right and wrong
Rules relied upon to
guide behavior and play, and provide
child with structure and security
5-6 yr: believe rules can
be changed
7-8 yrs: strict adherence
to rules
9-10 yrs: rules can be
negotiated
Begin understanding social roles;
regards them as inflexible; can adapt
behavior to fit different situations;
practices social roles
Takes on more responsibilities at home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self
interested exchanges
Emotional
Self esteem based on ability to perform and produce
Alternative strategies for dealing with frustrationand
expressing emotions
Sensitive to other’s opinions about themselves
6-9 yr: have questions about pregnancy, intercourse,
sexual wearing, look for nude pictures in books,
magazines
10-12 yr: games with peeing, sexual activity (e.g.,
strip poker, truth/dare, boy-girl relationships, flirting,
some
kissing, stroking/rubbing, reenacting intercourse with
clothes on)
Possible effects of maltreatment
Poor social/academic adjustment in school: preoccupied, easily
frustrated, emotional outbursts, difficulty concentrating, can be
overly reliant on teachers; academic challenges are threatening,
cause anxiety
Little impulse control, immediate gratification, inadequate coping
skills, anxiety, easily frustrated, may feel out of control
Extremes of emotions, emotional numbing; older children may
“self-medicate” to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting, lying,
stealing, breaking objects, verbal outbursts, swearing
Extreme reaction to perceived danger (i.e.,“fight, flight, freeze”
response)
May be mistrustful of adults, or overly solicitous,manipulative
May speak in unrealistically glowing terms about his parents
Difficulties in peer relationships; feel inadequate around peers;
over-controlling
Unable to initiate, participate in, or complete activities, give up
quickly
Attachment problems: may not be able to trust, tests commitment
of foster and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and
younger siblings
Emotional disturbances: depression, anxiety, post traumatic stress
disorder, attachment problems, conduct disorders
Physical Cognitive
Growth spurt: Formal operations: precursors in early
Girls: 11-14 yrs adolescence, more developed in middle and
Boys: 13-17 yrs late adolescence, as follows:
Puberty: Think hypothetically: calculate consequences of
Girls: 11-14 yrs thoughts and actions without experiencing them;
Boys: 12-15 yrs consider a number of possibilities and plan
Youth acclimate to changes in body behavior accordingly
Think logically: identify and reject hypotheses
or possible outcomes based on logic
Think hypothetically, abstractly, logically
Think about thought: leads to introspection and
selfanalysis
Insight, perspective taking: understand and
consider others’ perspectives, and perspectives
of social systems
Systematic problem solving: can attack a
problem, consider multiple solutions, plan a
course of action
Cognitive development is uneven, and impacted
by emotionality
Social
Young (12 – 14):
Psychologically distance self from
parents;identify
with peer group; social status largely
related to group membership; social
acceptance depends on conformity to
observable traits or roles; need to be
independent from all adults; ambivalent
about
sexual relationships, sexual behavior is
exploratory
Middle (15 – 17):
friendships based
on loyalty, understanding, trust; self-
revelationis first step towards intimacy;
conscious choices about
adults to trust; respect honesty & straight
for wardness from adults; may become
sexually active
Morality: golden rule;
conformity with law is necessary for good
of society
 Emotional
Psycho-social task is identity formation
Young adolescents (12-14): selfconscious about
physical appearance and early or late development;
body image rarely objective, negatively affected by
physical and sexual abuse; emotionally labile; may
over-react to parental questions or criticisms; engage in
activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others’ values,
beliefs; forms identity by organizing perceptions of
ones attitudes, behaviors, values into coherent “whole”;
identity includes positive self image comprised of
cognitive and affective components
Additional struggles with identity
formation include minority or biracial status, being an
adopted
child, gay/lesbian identity
Possible effects of maltreatment
All of the problems listed in school age
section
Identity confusion: inability to trust in self to be a
healthy adult; expect to fail; may appear immobilized
and without
Direction
Poor self esteem: pervasive feelings of guilt, self-
criticism, overly rigid expectations for self, inadequacy
May overcompensate for negative selfesteem by being
narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and aggressive,
antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with frequent and
violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
 Educational History  Current Situation

 Marriage Status  Religious History

 Social Activity  Criminal History

 Occupational History
 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

Psychosexual History
Socio-Economic History
• Economic Scale :

Validity
• Alloanamnesis :
• Autoanamnesis :
Symptom

Role of Function
Appearance

State of Consciousness

Speech
- Quantity :
- Quality :
 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
Non-cooperative Passive
Infantile
Indiferrent negativism
Distrust
Apathy Catalepsy
Labile
Tension Cerea flexibility
Rigid
Dependent Excitement
 Emotion

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

Hallucination Illusion
• Auditory (-)
• Auditory (-)
• Visual (-)
• Olfactory (-) • Visual (-)
• Gustatory (-) • Olfactory (-)
• Tactile (-) • Gustatory (-)
• Somatic (-)
• Undeferrentiated (-)
• Tactile (-)
• Somatic (-)
• Undeferrentiated (-)

Derealisation (-)
Depersonalisation (-)
 Thought Progression
Quantity Quality
• Irrelevan answer
• Incoherence
• Logorrhea • Flight of idea
• Blocking • Confabulation
• Remming • Poverty of speech
• Slow speech
• Mutisme • Loosening of association
• Talkative • 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 :
 General knowledge :
 Orientation of time/
place/people/situation :
 Working/short/long memory:
 Writing and reading skills :
 Ability to self care :
Impulse Control When Examined
• Self control :

• Patient response to examiners question:

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

 Conciousness :

 Vital sign:
- Blood pressure :
- Pulse rate :
- Temperature :
- RR :
•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 :

Symptoms Mental status Impairment

Axis I :
Axis II :
Axis III :
Axis IV :

Axis V : GAF
1. Problem about patient’s life (social)

2. Problem about patient’s biological state (biology)

3. Problem about patient’s mental state (psychology)

INPATIENT (HOSPITALIZATION)

Remissio
Response Recovery
n
 Serious risk of suicide
 Serious risk of harm to others
 Significant self-neglect
 Severe depressive symptoms
 Severe psychotic symptoms
 Lack or breakdown of social supports
 Initiation of ECT
 Treatment-resistant depression (where inpatient monitoring
may be helpful)
 A need to address comorbid conditions (e.g. physical
problems, other psychiatric conditions, inpatient
detoxification)

(Oxford Handbook of Psychiatry)

Emergency department
Target therapy :
50% decrease of symptoms

Maintenance
 Target therapy :
- 100% remission of symptom

 Inpatient management
-
 Outpatient management
-