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dr. Sabar P. Siregar, Sp. KJ


PERIODE 31 Agustus – 2 Oktober 2015
Dwi Erlinda Putri ( I11110012 )
Esti Nur Ekasari ( I11110025 )
Qory Irsan ( I11110028 )
Vidia Asriyanti ( I11110031 )
Wastri G. Manik ( I11109052 )
Desti Eryani ( I11110044 )
Erika Fitrianti ( I11110046 )
Novianus Erik Gibson ( I11110063 )


PERIODE 31 Agustus – 2 Oktober 2015
Patient’s Identity
Name : Mr. MK
Age : 16 years old
Gender : Male
Address : Griwetan, Grabag, Magelang
Occupation : Unemployed
Marriage Status : Unmarried
Ethnic : Java
Religion : Moslem
Last Education : Junior High School
No. MR : 00125032
PERIODE 31 Agustus – 2 Oktober 2015
History was obtained from alloanamnesion in September 13th
2015 in patient’s house
Identity I II
Name Mr. N Mrs. S
Age 72 years old 68 years old
Sex Male Female
Address RT 02/ RW 03, Dusun Garon, RT 02/ RW 03, Dusun Garon,
Tegalrejo, Magelang, Central Tegalrejo, Magelang, Central
Java Province Java Province
Ethnic Javanese Javanese
Religion Moslem Moslem
Occupation Pension Housewife
Marital State Married Married
Relation with Patient Father Mother


PERIODE 31 Agustus – 2 Oktober 2015
• History also obtained from autoanamnesion in
September 13th 2015 in patient’s house


PERIODE 31 Agustus – 2 Oktober 2015
The Reason Brought to Mental Hospital

• The patient was brought to RSJS Magelang by

his family on September 8th, 2015 because she
often felt confuse since 2 months ago.


PERIODE 31 Agustus – 2 Oktober 2015
Progression of Illnes
• Eighteen years ago (In 1997), the patient has changed
behavior without unknown reason.
• She began to rampage for no reason.
• She also didn’t want to eat or bath and couldn’t take care
of her children.
• The patient then was taken to "orang pintar", to be
treated. He said that the cause of those symptoms was
her husband, so she had to keep away from him. She and
her husband agreed with the deal.
• After a week, she didn’t rampage anymore, but she
seemed confuse. Several days later, her husband came to
meet her secretly. Apparently, the symptoms still not
recurred. Then, she was allowed to return with her
husband and stay at her parent in law‘s house.
Progression of Illnes
• Two years ago (in 2013), the patient brought to the RSJS
Magelang by her family because she has bizzare
• She was started to often talk to herself and often angry to
her parents and her children without any reason until she
damaged the door.
• In the house the patient was silent, dreamy, often angry
unclearly and looked confuse.
• She didn’t want to eat. Her teeth was broke by spoon
because her parents forced her to eat.
Progression of Illnes
• She couldn’t cook, clean the house and socialize with
neighbors. Because her parents worried about her
condition, so her parent brought her to the RSJS Magelang
for the first time.
• The patient was diagnosed paranoid schizophrenic by
• She was treated for 2 months and the patient came home
with improve condition. She didn’t rampage anymore. She
was able to clean the house, even though her mother said
that she still "seenake dewe". In spite of that, she was
unable yet to take care her childrens. This made them took
care by patient’s husband and parents in law, with dif
ferent house to live.
History of Past Illness
medis General Substance
illness medical illness abuse

There was no history

of high fever, seizure, The patient has no
head trauma, any history of subtance
other systemic abuse like drugs,
disease,or any other alcohol, and smoke.
serious illness which
needs hospitalization.


PERIODE 31 Agustus – 2 Oktober 2015
History of Personal Life

1. Prenatal and Perinatal History

2. Early childhood phase
3. Intermediate childhood
4. Late childhood
5. Adulthood


PERIODE 31 Agustus – 2 Oktober 2015
History of Personal Life

Prenatal and Perinatal Period

- She has two older brothers,
Patient is a third child. - One younger brother

 There was no valid data about prenatal history and mother pregnancy and
delivery, length of pregnancy, spontanity and normality of delivery, birth
trauma, whether the patient was planned or wanted, and also any birth
defect, how mother’s condition, and who was help of labor.
 There was no valid data about the condition of patient when she was born
such as activity (muscle tone), pulse, grimace (reflex irritability), appearance,
and respiration (APGAR score)
 There was no valid data about feeding habits of patient, is it breast feed or
bottle feed, was he having any eating problem.
Developmental History (Gross Motoric)

Ability Result Normal range

Elevating the head No Valid Data 0-3 months

Moving to supine No Valid Data 3-6 months

position on its own
Sitting No Valid Data 6-9 months

Standing No Valid Data 9-12 months

Walking No Valid Data 12-24 months

Climbing up the ladder No Valid Data 24-36 bulan

Standing 1 foot / jump No Valid Data 36-48 bulan

Developmental History (Fine Motoric)

Ability Result Normal range

Holding a pencil No Valid Data 3-6 months

Holding 2 objects at the same No Valid Data 6-9 months

Piling 2 cubes No Valid Data 9-12 months

Inserting objects into container No Valid Data 12-18 months

Rolling a ball No Valid Data 18-24 months

Doodling No Valid Data 24-36 months

Wearing shirt No Valid Data 36-48 months

Developmental History (Language)

Ability Result Normal range

Oooh-aah No Valid Data 0-3 months
Turning toward the sound No Valid Data 3-5 months

High-pitched sound No Valid Data 3-6 months

Voice without meaning (mamama, No Valid Data 6-9 months
Calling 2-3 syllables without meaning No Valid Data 9-12 months
Calling 3-6 words that have meaning No Valid Data 18-24 months
Talking at least with two words No Valid Data 24-36 months
Mentioning name, age, and place No Valid Data 36-48 months
Developmental History (Social & Personal)
Ability Result Normal range
Know their mother No Valid Data 0-3 months
Reach out No Valid Data 3-6 months
Clap No Valid Data 6-9 months

Playing peek a boo No Valid Data 6-9 months

Know their family No Valid Data 9-12 months

Appoint what he wants without No Valid Data 12-18 months
crying or whining
Tidy up toys No Valid Data 24-36 months
Playing with friends, follow the No Valid Data 36-48 months
rules of the game
Intermediate Childhood (3-11 years old )

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 was 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 was 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
Late Childhood and Teenage Phase
Sexual Development Sign and Activity (NO VALID DATA)
No data on when patient first menstruation, 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 Cognitive Social

Physically active Ego-centric, illogical, magical thinking Play:

Rule of Three: 3 yrs,3 ft, 33 Explosion of vocabulary; Cooperative,imaginative, may involve
lbs. learning syntax, grammar; fantasy and imaginary friends, takes turns
Weight gain: 4-5 lbs per year understood by 75% of people by age 3 in games
Growth: 3-4 inches per year Poor understanding of time, Develops gross and fine motor skills;
Physically active, can’t sit still value, sequence of events social skills;
for long Vivid imaginations; some experiment with social roles;reduces fears
Clumsy throwing balls difficulty separating fantasy Wants to please adults
Refines complex skills: from reality Development of conscience:
hopping, jumping, climbing, Accurate memory, but more Incorporates parental prohibitions; feels
running, ride “bigwheels” and suggestible than older children guilty when disobedient; simplistic idea of
tricycles Primitive drawing, can’t “good and bad” behavior
Improving fine motor skills represent themselves in drawing till age 4 Curious about his and other’s bodies, may
and eye-hand coordination: Don’t realize others have masturbate
cut with scissors, draw shapes different perspective No sense of privacy
3– 3,5 yr: most toilet trained Leave out important facts Primitive, stereotypic
May misinterpret visual cues of emotions understanding of gender roles
Receptive language better
than expressive till age 4
Emotional Possible effects of maltreatment
Self-esteem based on what others tell Poor muscle tone, motor coordination
him or her Poor pronunciation, incomplete sentences
Increasing ability to control emotions; Cognitive delays; inability to concentrate
less emotional outbursts Cannot play cooperatively; lack curiosity, absent imaginative
Increased frustration tolerance and fantasy play
Better delay gratification Social immaturity: unable to share or negotiate with peers;
Rudimentary sense of self overly bossy, aggressive, competitive
Understands concepts of right and Attachment problems: overly clingy, superficial attachments,
wrong show little distress or over-react when
Self-esteem reflects opinions of separated from caregiver
significant others Underweight from malnourishment; small stature
Curious Excessively fearful, anxious, night terrors
Self-directed in many activities 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
Poor self esteem, confidence; absence of initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses
Eneuresis, encopresis, self stimulating behavior –rocking,
School Aged
Physical Cognitive Social
Slow, steady growth: Use language as acommunication tool Friendships are situation
3 -4 inches per year Perspective taking: specific
5-8 yr: can recognize others’ perspectives, Understands concepts
Use physical
can’t assume the role of the other of right and wrong
8–10 yr: recognize difference between Rules relied upon to
to develop gross and behavior and intent; age guide behavior and play, and provide child with
fine motor skills 10-11 yr: can accurately structure and security
Motor & perceptual recognize and consider 5-6 yr: believe rules can
motor skills better others’ viewpoints be changed
integrated Concrete operations: 7-8 yrs: strict adherence
Accurate perception of to rules
10-12 yr: puberty
events; rational, logical 9-10 yrs: rules can be
begins for some
thought; concrete thinking; reflect upon self negotiated
children and attributes; understands concepts of Begin understanding social roles; regards them
space, time, dimension as inflexible; can adapt behavior to fit different
Can remember events situations; practices social roles
from months, or years Takes on more responsibilities at home
earlier Less fantasy play, more
More effective coping skills team sports, board games
Understands how his Morality: avoid punishment; self interested
behavior affects others exchanges
Emotional Possible effects of maltreatment
Self esteem based on ability to Poor social/academic adjustment in school: preoccupied, easily
perform and produce frustrated, emotional outbursts, difficulty concentrating, can be overly
Alternative strategies for dealing reliant on teachers; academic challenges are threatening, cause anxiety
with frustrationand expressing Little impulse control, immediate gratification, inadequate coping skills,
emotions anxiety, easily frustrated, may feel out of control
Sensitive to other’s opinions Extremes of emotions, emotional numbing; older children may “self-
about themselves medicate” to avoid negative emotions
6-9 yr: have questions about Act out frustration, anger, anxiety with hitting, fighting, lying, stealing,
pregnancy, intercourse, sexual breaking objects, verbal outbursts, swearing
wearing, look for nude pictures Extreme reaction to perceived danger (i.e.,“fight, flight, freeze”
in books, magazines response)
10-12 yr: games with peeing, May be mistrustful of adults, or overly solicitous,manipulative
sexual activity (e.g., strip poker, May speak in unrealistically glowing terms about his parents
truth/dare, boy-girl relationships, Difficulties in peer relationships; feel inadequate around peers; over-
flirting, some controlling
kissing, stroking/rubbing, Unable to initiate, participate in, or complete activities, give up quickly
reenacting intercourse with Attachment problems: may not be able to trust, tests commitment of
clothes on) foster and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and younger
Emotional disturbances: depression, anxiety, post traumatic stress
disorder, attachment problems, conduct disorders
Physical Cognitive Social

Growth spurt: Formal operations: precursors in early Young (12 – 14):

Girls: 11-14 yrs adolescence, more developed in middle and Psychologically distance self from
Boys: 13-17 yrs late adolescence, as follows: parents;identify
Puberty: Think hypothetically: calculate consequences with peer group; social status largely
Girls: 11-14 yrs of thoughts and actions without experiencing related to group membership; social
Boys: 12-15 yrs them; consider a number of possibilities and acceptance depends on conformity to
Youth acclimate to changes in plan behavior accordingly observable traits or roles; need to be
body Think logically: identify and reject hypotheses independent from all adults;
or possible outcomes based on logic ambivalent about
Think hypothetically, abstractly, logically sexual relationships, sexual behavior is
Think about thought: leads to introspection exploratory
and selfanalysis Middle (15 – 17):
Insight, perspective taking: understand and friendships based
consider others’ perspectives, and perspectives on loyalty, understanding, trust; self-
of social systems revelationis first step towards
Systematic problem solving: can attack a intimacy; conscious choices about
problem, consider multiple solutions, plan a adults to trust; respect honesty &
course of action straight for wardness from adults; may
Cognitive development is uneven, and become sexually active
impacted by emotionality Morality: golden rule;
conformity with law is necessary for
good of society
Emotional Possible effects of maltreatment

Psycho-social task is identity formation All of the problems listed in school age
Young adolescents (12-14): selfconscious about section
physical appearance and early or late development; Identity confusion: inability to trust in self to be a healthy adult;
body image rarely objective, negatively affected by expect to fail; may appear immobilized and without
physical and sexual abuse; emotionally labile; may Direction
over-react to parental questions or criticisms; engage Poor self esteem: pervasive feelings of guilt, self-criticism, overly
in activities for intense rigid expectations for self, inadequacy
emotional experience; risky May overcompensate for negative selfesteem by being
behavior; blatant rejections of narcissistic,
parental standards; rely on peer unrealistically self-complimentary;
group for support grandiose expectations for self
Middle adolescents (15-17): May engage in self-defeating, testing, and aggressive, antisocial,
examination of others’ values, or impulsive
beliefs; forms identity by organizing perceptions of behavior; may withdraw
ones attitudes, behaviors, values into coherent Lack capacity to manage intense
“whole”; identity includes positive self image emotions; may be excessively labile, with frequent and violent
comprised of cognitive and affective components mood swings
Additional struggles with identity May be unable to form or maintain
formation include minority or biracial status, being an satisfactory relationships with peers
adopted Emotional disturbances: depression,
child, gay/lesbian identity anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
Educational History
– She entered elementary school when she was six
years old. She graduated from elementary school
and continue her study to junior high school but
she didn’t continue her study to senior high school.
– There is no valid data about patient school history,
her prestation, relationship with teachers, favourite
studies. There is also no valid data about patient’s
participation in sport and hobbier, his attitude at
school, how many her friends, social popularity,
participation in group activities,


PERIODE 31 Agustus – 2 Oktober 2015
 Marriage Status
 Social Activity
 Occupational History
 Current Situation
 Religious History
 Criminal History


PERIODE 31 Agustus – 2 Oktober 2015
Erikson’s Stages of Psychosocial
Stage Basic Conflict Important Events
Infancy (birth to 18 months) Trust vs mistrust Feeding
Early childhood (2-3 years) Autonomy vs shame and 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 Intimacy vs isolation Relationship
Middle adulthood (40-65 Generativity vs stagnation Work and parenthood
Maturity(65- death) Ego integrity vs despair Reflection on life

Conclusion: no clear data

Family history
• The patient was the 3rd child from 4 siblings
• The patient lived with his father, and his mother
• There was no psychiatric history in patient’s family

Psychosexual History
• Patient’s psychosexual history is appropriate to his
gender. The patient realizes that he is male and she
behaves according to his gender. She prefer to play with
peers female friends. There is no valid data about the
first time she attracted to male.


PERIODE 31 Agustus – 2 Oktober 2015
Sosio-economi history

• Economic scale : Low. The patient was unemployed and

patient’s income just depended on his family.

• Alloanamnesis : Valid Data
• Autoanamnesis : Valid Data


PERIODE 31 Agustus – 2 Oktober 2015


Role of Function
Mental State (September 13th 2015, 12.30 p.m)

A female that inappropriate to her age, weared
completely clothes and had poor self care
State of Consciousness
• Connection of psychic
Attention easily attracted, unable to sustained
concentration (+)
Hypoactive Psychomotor
Automatism agitation
Bizarre Compulsive
Command Ataxia
Active negativism Mimicry
Cataplexy Aggresive
Stereotypy Impulsive
Non-cooperative Passive
Indiferrent negativism
Apathy Catalepsy
Tension Cerea flexibility
Dependent Excitement

• Quantity
Decrease (+)

• Quality
Decrease (+)

Mood Affect
• Appropriate
• Dysphoric • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
Disturbance of Perception

Hallucination Illusion
• Auditory • Can’t be assessed
• Visual
• Olfactory
• Tactil
• Can’t be assessed

Derealisation can’t be
Depersonalisation can’t
be assessed
Thought Progression
Quantity Quality
• Irrelevan answer
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Confabulation
• Mutisme • Poverty of speech
• Talkative • Slow speech
• 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 : Moderate

 General knowledge : yet to be evaluated
 Orientation of time/
place/people/situation : yet to be evaluated
 Working/short/long memory : yet to be evaluated
 Concentration : Lack
 Writing and reading skills : Less
 Ability to self care : Less
Impulse Control When Examined
• Self control : poor
• Patient response to examiners question:
• Impaired insight (patient do not know he
is mentally ill)
• Intelectual Insight
• True Insight (Patient didn’t know he is
mentally ill and didn’t want go to hospital
to cure his illness.
Physical Examination

 Conciousness : compos mentis

 Vital sign:
- Blood pressure : 120/70 mmHg
- Pulse rate : 84 x/min
- RR : 20x/min
- Temperature : 36,5o C
Review System
a. Head :
 normocephali, mouth deviation (-)
 anemic conjungtiva (-), icteric sclera (-), pupil isocore
b. Neck : normal, no rigidity, no palpable lymph nodes
c. Thorax :
 Cor : S1 S2 regular, murmur -, gallop -
 Lung : vesicular sound +/+, wheezing -/-, ronchi-/-
d. Abdomen :
 Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness -, mass -, liver, spleen and
kidney not papable
e. Extremity : Warm acral, capp refill <2”, edema (-)
Neurogical Examination
Physiological reflex (Not asessed)
Upper extremities: biceps reflex , triceps reflex ,
Lower extremities: patella reflex , achilles tendon reflex

Pathological reflex (Not asessed)

Upper extremities: Hoffman , Tromner
Lower extremities: babinski,
chaddok,gordon,oppenheim, rossolimo

Motoric examination
Normal movement, good coordination, normal strength
Neurological Status
• Motorik : Normotonus, good coordination of movement

• Meningeal sign : Not asessed

• Physiologic reflex : Not asessed

• Patologic reflex : Not asessed

Neurogical Examination
Cranial nerves examination:
CN I : Not asessed
CN II : Not asessed
CN III,IV,VI : Not asessed
CN V : Not asessed
CN VII : Not asessed
CN VIII : Not asessed
CN IX : Not asessed
CN X : Not asessed
CN XI : Not asessed
CN XII : Not asessed
A Female, 40 years of come to poly psychiatrist RSJS with his father on
8 sept 2015. to take medication. During the interview the patient
speaks only a little and only “cengar cengir” sometimes shook and
nodded her head. Visual and verbal contact is less.

Her father also said she often confused. Her dad also said that she
experienced this complaint more than 18 years ago, often recurrent
and became heavy since 2 months ago. She also often disconnected
when spoken to her. She was always slow and just smiled when
giving an answer.

When asked about the development history of the patient, the

patient of the minor is indeed a shy child, rarely spoke, and closed
more than happy to do things as he wishes it. So the relationship with
friends and neighbors do not so close in general. Patients arranged
marriage, and after marriage patients living at home-in-law, and who
take care of the household is her husband
Patients had a history of bizzzare behavior in the past 18 years, often furious and
angry. After one week, the patient finally be brought to a witchdoctor. And patients
can indulge back but still often silent and preoccupied.

The patient's father began to realize that more and more patients are often
confused and long when answering when asked, and the patient looks gloomy.
And sometimes like children who like to play with water and soap. Since the
patient is getting harder to get along with the neighbors.

In 2013 the patient re-experiencing strange behavior. Patients suddenly lash out and
slammed the door slam, brought to the smart people do not change, eventually treated
in mental hospital for 2 months with a diagnosis of paranoid schizophrenia.

Patients condition improved but the patient is getting closed. do not want to clean the
house, it is difficult if asked, and all the housekeeping was done by his mother and
who take care of children is her husband. Now the patient said she was sad. Often
forgotten, sleep disorders and lazy and tired quickly want why doing. Since the last 2
months paien was in his parents' home and feel embarrassed to meet a child, husband
and in-laws.
Syndrome of mental Schizoid personality
Syndrome of depression
retardation disorder
•Less visual and verbal •Less able to express
contact warmth, softness
•Mood dysphoric •Abulia
•Loss of excitement keada others
•Infantile •Schizoid personality
•Reduce energy, •Poor idea
lackness disorder
•Remming •Almost always
•Decrease of •Less concentration
concentration choose their own
Autism activities conducted
•Sleep disturbance •Early onset (<18 years
•Less of self confidens •Not have a close
old) friend or a close
•Depresion syndrom personal relationship
•Adaptive behavior less
•Useless free time
•Function diminished role
•Poor self care
Hospitalization • No indication

• Antidepressant (Fluoxetine 1 x 20 mg): (SSRI)

have little or no affinity for alpha-adrenergic
histamine or chollinergic receptor, it has low
side effect rather than others Antidepressant
• Antipsychotic (Risperidone 2 x 2 mg):
Respons Phase Second-generation atypical antipsychotic. It
is a dopamine antagonist possessing anti-
serotonergic, anti-adrenergic and anti-
histaminergic properties.
• 100% remission of symptoms
Remission Phase • Continue the pharmacotherapy

• The patient must be taking medication

regularly and control to psychiatric
• Family education : tell to her family
about her problem and her mental disorder
and how to treat it; Provide guidance to the
Recovery Phase family to keep active role in every patient
management process; Briefed the families
about the importance of the drug to the
patient's recovery so families need to remind
and monitor the patient to take medication
Terima kasih
Mohon masukan dan
saran 