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Tuesday , December 11th, 2012

Supervisor :
dr Sabar P Siregar Sp.Kj
PATIENTS IDENTITY
Name : Miss K
Age : 40 years old
Gender : Female
Address : Temanggung
Occupation : Unemployee
Marital status : Single
Last education : no education

Alloanamnesis
Name : Mrs. M
Age : 31 years old
Relation : Sister
ANAMNESIS
Chief complaint : run amuck
PRESENT HISTORY (alloanamnesis)
Since her mom died 6 years ago, the patient begin: run amuck,
take a walk and back home in the evening, throw a stone to the
neighbours home, hit anyone in front of her or pull of hair,
sometimes walk nakedly in the road, smile-laugh to herself, and get
over eating. Her sister unable to take care of patient at home.

The patient also doesnt want to work such as clean home and
wash plates or glass like before her mom died. When reminded to eat
or take a bath, sometimes she get angry immediately.






PAST ILLNESS HISTORY


Psychiatry history

General medical
history

Drugs and alcohol
abuse history and
smoking history

Patient borned with
deaf mute. She is a
irritable woman, often
angry since as a
children. She also
smile-laugh to herself.
Her parents never
complain to doctor
about patients
condition. At home, she
still able to do a little of
home tasks like washing
plate and cleaning the
house.
Hypertension (-)
Head injury (-)
Asthma (-)
Febrile seizure (-)
Deaf-mute (+) since
patient borned and
wasnt be examined to
doctor.

Alcohol consumption(-)
Tobacco consumption
(-)
Drug use (-)

History of Personal Life

Prenatal and Perinatal History
There were no valid data about her mother condition when shes pregnant
and the patient condition when delivered.

Early Childhood Phase (0-3 Years Old)
Psychomotoric
There were no valid data about patients growth and development.
Psychosocial
There were no valid data about patient started smiling when seeing another
face.
Emotion
There were no valid data about patient 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 understanding simple orders.

Intermediate Childhood (3-11 y.o)
Psychomotor
No valid data .
Psychosocial
Patients gender identification is normal
Communication
Patient had no friend and unable to socialized well.
Emotional
Patient was iritable.
Cognitive
No valid data
Late Childhood & Teenage Phase
Sexual development signs & activity
No valid data
Psychomotor
No valid data
Psychosocial
Patient had no friend and unable to socialized well.
Emotional
Patient is iritable.





Adulthood
Educational and Occupational History :
No school and no job
Marital status :
Unmarried
Legal History :
Never been arrested or caught by police.
Social Activity :
No social activity.
Current Situation :
Living with her sister, the sisters husband.
Religious History :
Nothing

No another one of family that has a psychiatric
disorder.
Family History

Psychosexual history
No valid data.
Socio-economic history :
Economic scale: low
Validity
Alloanamnesis : valid
Autoanamnesis: invalid

Genogram
Progression of Ilness
Symptoms
born 2007 2012
Role of
function
III. Mental State

Appearance :
Adult woman, appropriate according to age, dressed
appropriately
State of Consciousness
Cant be assessed
Speech:
Quantity : Decreased
Quality : Decreased
Behaviour
Normoactive
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Mannerism
Automatism
Command automatism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

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

Derealisasi
Illusion
Auditory
Visual
Olfactory
Gustatory
Tactile
Somatic

Depersonalisasi

Cant be assesed
Thinking
thought progression
Quantity
Logorrhea
Blocking
Remming
Mutisme
Talk active

Quality
Relevan answer
Irrelevan answer
Incoherence
Flight of idea
Confabulation
Poverty of speech
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia

Cant be assesed
Thought Process
content of thought
Idea of reference
Preokupasi
Obsesi
Fobia
Delution of persecution
Delution of Reference
Delution of envious
Delution of hipokondri
Delution of Grandeous

Delusion of magic-mistic
Delusion of control
Delusion of influence
Delusion of passivity
Delusion of perception
Thought of echo
Thought of insertion/withdrawal
Thought of broadcasting

Cant be assesed
Thought form
Realistic
Non Realistic
Dereistic
Autistic

Cant be assesed
SENSORIUM and cognition
Level of education : never get education
General knowledge : cant be assessed
Orientation of time : cant be assessed
place : cant be assessed
people : cant be assessed
situation : cant be assessed
Working/short/long memory : cant be assessed
Writing and reading skills : cant be assessed
Visuospatial : cant be assessed
Abstract thinking : not evaluated
Ability to self care : bad

Impulse control when examined :
Self control : enough
Patient response to examiners question: no response

Insight
Impaired insight
Intelectual Insight
True Insight
Cant be assessed



IV. PHYSICAL EXAMINATION
Conciousness : compos mentis
Vital sign:
Blood pressure : 140/90 mmHg
Temperature : afebris

Head : normocephali
Eyes : anemic conjungtiva -/-, icterik sclera
-/-, pupil isocore
Neck : normal, no rigidity, no palpable
lymphnode
Thorax:
Chor : S1 and S2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain - , peristaltic normal, thympany sound
Extremity : Warm acral, capp refill <2

SIGNIFICANT FINDING RESUME
Onset

Mental Status

Impairment

Since 5 years ago (1 year
after her mother died),
the patient begin :
run amuck, take a walk
and back home in the
evening, throw a stone
to the neighbours
home, hit anyone in
front of her or pull of
hair, sometimes walk
nakedly in the road,
smile-laugh to herself,
and get over eating.
Stereotypi behavior
Infantile attitude
Restrictive affect

Dellusion and
halusination cant be
assessed.
Role function: inability
to work.

Spare time: take a walk

Psychosocial : bad
socialization

Ability to self care :
enough grooming

Differential Diagnose
F20.0 Paranoid Schizophrenia
F20.2 Cathatonic Schizophrenia
F73 Extreme Mental Retardation
F78 Other Mental Retardation
F84.4 Over Activity Disorder related with Mental
Retardation and Stereotypic Movement

VII. DIAGNOSTIC FORMULATION
Axis I : F20.0 Cathatonic Schizophrenia
Axis II : F73 Extreme Mental Retardation
Axis III : Deaf-mute (congenital disorder)
Axis IV : Her mother died five years ago, deaf-
mute
Axis V : GAF 20-11

Therapy Planning
Hospitalized, because the sister unable to take care of patient at home
and because the patient disturb other people and environment.
Medication
ER : Lodomer 5mg Inj 1 Amp (IM)
Room therapy:
Haloperidol
Psychososial therapy

Mental Retardation treatment :
Medical care : comphrehensive management plan from multiple
disciplines including special educators, language therapists, behavioral
therapists, occupational therapists (improve physical activity and
acquire skills for living), and community service (Panti Tuna Rungu).
Regular physical activity, because obesity is more prevalence in those
with MR

Family education
Explain to his family about this patient mental disorder
Describes steps of treatment
Family must keep in touch with patient intensively, so the patient will
not feel lonely.


Ad vitam : Ad Bonam
Ad functionum : Dubia ad malam
Ad sanationum : Ad Malam