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Wednesday, 6th March 2014

SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

Name : Mrs. Y

Gender Address Occupation Last Education school

: 66 y.o
: Female : Magelang : Farmer : Elementary

Marriage status : Married

Patient was brought to the emergency unit by her daughter and neighbour

Name: Mrs. S Alloanamnesis had been done from: Age: 39 y.o

Relation: daughter

The reasons of patient was brought to hospital

Wandering around


She jealous with her husband

Present History
1.5 years ago 3 weeks ago

Patient started to hear voice without the source Looks talk to herself

Patient : - cant sleep - Easy to get angry - Rage violently - Talk to herself - Wandering around

Good utilization of leisure time No social withdrawal She still work well She can taking care to herself

Poor utilization of leisure time Social withdrawal She cant work well She cant taking care to herself

Present History
Day of admission

Patient : - Wandering around - cant sleep - Easy to get angry - Rage violently - Talk to herself - Patient start to forgot anything.
She couldnt work well Poor utilization of leisure time Social withdrawal Cant communicate well She cant taking care to herself

Psychiatric History
There was no psychiatric history before.

General medical history

Head injury (-) Hypertension (-) Convulsion (-) Asthma (-) Allergy (-) History of admission (-)

Drugs and alcohol abuse history and smoking history

Drugs consumption (-) Alcohol consumption (-) Cigarette Smoking (-)


Psychomotoric (NO VALID DATA)

first time lifting the head rolling over Sitting Crawling Standing walking-running holding objects in her hand putting everything in her mouth

Psychosocial (NO VALID DATA)

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 VALID DATA) No valid data about when the patient started saying words 1 year like mom or dad.

Emotion (NO VALID 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 VALID DATA) There were no valid data on which age the patient can follow objects, recognizing her mother, recognize her family members. (the mother forgot about it) There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders.


Psychomotor (NO VALID DATA) No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports. Psychosocial (NO VALID DATA) No valid data on patient interaction with her surrounding, no valid data on when patient first entered primary school, on how well patient handle separation from parent, how well she play with her new friend on first day school. Communication (NO VALID DATA) She was not talking too much with her friends. Emotional (NO VALID DATA) No valid data on patients adaptation under stress, any incidents of bedwetting were not known. Cognitive (NO VALID DATA) She always passed all grade of elementary school.


Sexual development signs & activity (NO VALID DATA) First experience of menstruation , Psychomotor (NO VALID DATA) She had no activity and didnt do her hobbies Psychosocial (NO VALID DATA) Patient had never been told the parent about patients friend. Emotional (NO VALID DATA) No valid data on patients reaction on playing, scared, showed jealously or competitiveness Communication (NO VALID DATA) Patient sometimes talks to her family but often kept her problems alone

Educational History
post graduated from elementary school. There is no data about her achievement during her school.

Social Activity
she has good relationship with her friends, neighbours

Occupational history
She works as a farmer with her husband

Current Situation
She lives with her husband.

Marital Status
Married. Have a good relationship with her husband. But 3 weeks ago she looked forget with her husband.

Criminal History

Eriksons stages of psychosocial development

Stage Infancy (birth to 18 months) Early childhood (2-3 years) Preschool (3-5 years) School age (6-11 years) Adolescence (12-18 years) Basic Conflict Trust vs mistrust Autonomy vs shame and doubt Initiative vs guilt Industry vs inferiority Identity vs role confusion Important Events Feeding Toilet training Exploration School Social relationships

Young Adulthood (19-40 years)

Middle adulthood (40-65 years) Maturity (65- death)

Intimacy vs isolation
Generativity vs stagnation Ego integrity vs despair

Work and parenthood Reflection on life

Family history
Patient is the last child out of 6 Psychiatry history in the family : -


Suffers from mental illness

Female Male

Psychosexual history
Patient knows that she is female, her behavior is appropriate for female and is attracted to male. She is now married and has three daughter

Socio-economic history Economic scale : low


Alloanamnesis Autoanamnesis

: not valid : not valid

Progression of disorder



Role function

Mental State (Wednesday, 6th March 2014)

A female, appropriate to her age, completely clothed

State of Consciousness

Quantity : normal Quality : decreased

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


Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Passive

Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility Excitement

Dysphoric Euthymic Elevated Euphoria Expansive Irritable Agitation

Appropriate Inappropriate Restrictive Blunted Flat Labile

Disturbance of perception
Auditory (+) Visual (+) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Illusion Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)

Thought progression
Quantity Quality
Irrelevant answer Incoherence Flight of idea Poverty of speech Confabulation Loosening of association Neologisme Circumtansiality Tangential Verbigrasi Perseverasi Sound association Word salad Echolalia

Logorrhea Blocking Remming Mutism Talk active

Content of thought

Idea of Reference Idea of Guilt Preoccupation Obsession

Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Delusion of Suspicious Thought of Echo

Delusion of Persecution Delusion of Reference Delusion of Envious Delusion of Hipochondry Delusion of magic-mystic

Thought of Insertion/withdrawal
Thought of Broadcasting

Form of thought

Realistic Non Realistic Dereistic Autistic

Sensorium and Cognition

Level of education Orientation of time Orientations of place Orientations of peoples Orientations of situation Working/short/long memory Writing and reading skills Visuospatial Abstract thinking Ability to self care

: low : bad : bad : Good : bad : bad : Good : Good : bad : bad

Impulse control when examined

Self control: Good Patient response to examiners question: Good

Impaired insight Intellectual Insight True Insight

Internal Status



TD : 160/1000mmHg
Pulse rate : 96x/m




: 20x/m

Temperatur : afebris

Head : normocephali

anemic conjungtiva -/-, icteric sclera -/-, pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes


Inspeksi : IC did not show

Palpasi : normal

Perkusi : Dull

Auskultasi : S 1,2 Sound and normal


Inspeksi : Enlargement ICS (-), retraction (-),

Palpasi : strem fremitus dextra = sinistra

Perkusi : resonance

Auskultasi : vesicular sound, wheezing -/-, ronchi-/-


Inspeksi : Flat

Auskultasi : normal peristaltic, tympany sound

Perkusi : Timpani,

Palpasi : Pain (-) ,

Ekstremitas Superior <2/<2 +/+ Inferior <2/<2 +/+

capp refill, Warm acral

Neurological exam : not examined

Mental Status
Mood elevated Dereistic
Wandering around cant sleep Easy to get angry Rage violently Talk to herself

She couldnt work well Poor utilization of leisure time Social withdrawal She cant taking care to herself

Hallucination visual
Hallucination auditorik Impaired insight Disorientasi time, place, and situational

Differential Diagnosis
FO1.0 Dementia Vascular F20.0 paranoid scizophrenia F06.0 organic hallucination

Multiaxial Diagnosis

Axis I Axis II Axis III Axis IV Axis V

: FO1.0 Dementia Vascular F20.0 paranoid scizophrenia : R46.8 delayed diagnosis of axis II : Hypertension grade 2 : jealous with her husband : GAF admission 30-21

Problem Related to Patient Organobiology There were high blood pressure that can cause abnormality on vascular especially on brain vascular so may can lead to the dementia and other symptoms. Psychology There were severe impairment and psychic function, so that he need pharmacology. Sociology There were severe impairment in society, work, and utilization of leisure time.

Hospitalization Because she wandered around, and rage violently




Target therapy
suppress and stabilize symptoms (decrease 50% symptoms) wandered around, hallucination auditoric and visual Decrease the blood pressure

Emergency department

Antipsychotics : Inj. Haloperidol 5mg IM Positive symptoms in patient will respond with typical antipsychotic

Antipsychotics : Tab Haloperidol 2 x 5 mg Continue the medication from Emergency Department In psychosis symptoms, there was hyperactive of dopamine. Typical antipsychotics act primarily by blocking central D2 receptor in post synaptic neuron especially in Lymbic system and extrapyramidal effective to positive symptom Anti Hipertention : Captopril 12.5 mg.

Re-assess patients when cooperative


Target therapy

Improvement in function, cognition (symptoms decrease 100% in 4-9 months)

Inpatient management


Increasing quality of life

Target therapy

vocational and social autonomy (symptom has already gone 100% for minimal 1 year)

Pharma cothera py

Education to family

Outpatient management

Rehabilita tion

Psychothe rapy