morport irvan
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SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
Saturday, May 24th 2014
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Patient IdentityAutoanamnesis
Name : Mrs. U
Sex : Female
Age : 22 years old
Address : Krandan kebonrejo Salaman Magelang
Occupation : Textile employment
Marital State : Divorcee
Alloanamnesis
Name : Mrs. K
Sex : Female
Relation : Mother
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Reason patient was brought
to emergency room
Patient feel very exhausted everyday
and doesnt work for a 12days
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Stressor
Divorced with her husband
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Past History
Patient has no psychiatricproblems before
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Past History
Patient got married with her husband
Patient got an info that her husband cheating her
Patient force her husband to leave her parent house
Patient officialy divorced with her husband
Patient officialy divorced with her husband
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Day of Admission
24th May 2014
atient brought with the complaints of
Patient always feel exhaustedPatient lost of interest in her hobby
Patient no appatite
Patient Cant concentrate
Cant start to sleepFeel guilty
Brought to hospital byhis mother
Now patient didnt worked as a Textile employment for 12 days
Poor utilization of leisure time
Sometimes took a wrong way to go to her house
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PSYCHIATRIC HISTORY
Patient has no psychiatric problems
history before
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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric
- There were no valid data on patients growth and development such as: first time lifting the head (3-6 months)
rolling over (3-6 months)
Sitting (6-9 months)
Crawling (6-9 months)
Standing (6-9 months) walking-running (9-12 months)
holding objects in her hand(3-6 months)
putting everything in her mouth(3-6 months)
Psychosocial- There were no valid data on which age patient
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)
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Communication
There were no valid data on when patient started bubbling. (6-9 months)
Emotion
There were no valid data of patientsreaction 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 his mother, recognize his family members.
- There were no valid data on when the patient first copied sounds thatwere heard, or understanding simple orders.
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INTERMEDIATE CHILDHOOD (3-11 YEARS
OLD)
PsychomotorNo valid data on when patientsfirst time playing hide and seek
or if patient ever involved in any kind of sports.
Psychosocial
No valid data regarding patient psychosocial.Communication
No valid data regarding patient ability to make friends at school
and how many friends patient have during his school period
Emotional
No valid data on patientsemotional.
Cognitive
No valid data on patientscognitive.
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LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity (NO VALID DATA)No data on when patient first experience of wet dream, ect.
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 regarding patient psychosocial.
Emotional (NO VALID DATA)
No valid data on patientsemotional.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school
and how many friends patient have during his high school period
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ADULTHOOD
Educational HistoryHe finished senior high school
Occupational History
she started to work as a textileemployment when she was
20 year old.
Her mother didntknow
anything about her occupation.
Marital Status
Married once in 19 yo.
she was good wife and
has live in harmony with
her husband.
She doesnt have any
children with her husband
Criminal History
No
Social Activity
She was a friendly girl and had many
friends
Current SituationShe lives with her parents, being alone.
And she wasnt working as a driver
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Eriksons stages
of psychosocial developmentStage Basic Conflict Important Events
Infancy
(birth to 18 months)
Trust vs mistrust Feeding
Early childhood
(2-3 years)
Autonomy vs shame and doubt 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 years)
Intimacy vs isolation Relationship
Middle adulthood
(40-65 years)
Generativity vs stagnation Work and parenthood
Maturity
(65- death)
Ego integrity vs despair Reflection on life
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FAMILY HISTORY
Patient is the only child
There is no psychiatry history in the family
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Male Female Patient Divorced
GENOGRA
M
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PSYCHOSEXUAL HISTORY
Patient realizes that he is a female, and interested in
male. His attitude is appropriate as a female.
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Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
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Progression of Disorder
Symptom
Role Function
2011 2014
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Appearance
A female, appropriate to his age, completely
clothed, nicely groomed
State of Consciousness
Clear
Speech
Quantity : Normal
Quality : Normal
Mental StateMay 24th2014
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BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
CatatoniaActive negativism
Cataplexy
Streotypy
Mannerism
AutomatismBizzare
Command automatism
Mutism
Acathysia
Tic
SomnabulismPsychomotor agitation
Compulsive
Ataxia
Mimicry
AggresiveImpulsive
Abulia
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ATTITUDE
Non-cooperative
Indiferrent
Apathy
Tension Dependent
Passive
InfantileDistrust
Labile
Rigid
Passive negativismStereotypy
Catalepsy
Cerea flexibility
Excited
Stable
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Emotion
Mood
Dysphoric
Euthymic Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Inappropriate
Broad Restrictive
Blunted
Flat
Labile
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Disturbance of Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
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Thought Progression
Quantity
Logorrhea Blocking
Remming
Mutism
Talkative
Quality
Irrelevant answer
Incoherence Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
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Content of Thought
Idea of Reference Idea of Guilt
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of Magic-mystic
Delusion of Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicion
Thought of Echo
Thought of Insertion & withdrawal
Thought of Broadcasting
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Form of Thought
RealisticNon Realistic
DereisticAutism
Cannot be evaluated
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Sensorium and Cognition
Level of education : finished junior highschool
General knowledge : good
Orientation of time : good Orientations of place : good Orientations of people : good Orientations of situation : good Working/short/long memory: good
Writing and reading skills : good Visuospatial : good Abstract thinking : good Ability to self care : good
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Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 129/76mmHg
Pulse rate : 100x/min
Temperature : Afebrile
RR : 22 x/min
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Review System
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill
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Mental Status Impairment
- Behavior:hypoactive
- Mood: Dysphoric
-Thought Progression: -
- Form of Thought : -
Patient always feel
exhausted
Patient lost of interest
in her hobby
Patient no appatite
Patient Cant
concentrate
Cant start to sleep
Feel guilty
Patient doesnt work
for a 12days
Patient has a poor
utilization of her
leisure time
Patient sometimes
confuse to choose
wich way to go to her
house
Symptoms
Patient is a female, 22 years old, nicely groomed,has no history of admittion in psychiatric ward.
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Differential Diagnosis
F25.3 Schizo affective disorder depression type
F32.2 Depression without psychotic symptom
F43.2 Post Traumatic Stress Disorder
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Multiaxial Diagnosis
Axis I : F32.2 Depression without psichotic
symptom
Z91.1 Noncompliance of medicationAxis II : R46.8 Delayed diagnosis of Axis II
Axis III : no diagnosis
Axis IV : Divorcee with her husband
Axis V : GAF admission 40-31
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1. Problem about patients life
- Patient married with her husband in 19 years old .
- Patient leave with her husband in her parent house
- When 2 Months of their marrital age, patient got an info that her husband
cheating her
- When patient got a mad with her husband, her husband slap her
- Patient force her husband to leave her parent house
- Patient resolving her divorcing status to the court alone
2. Problem about patients biological state
There were abnormality imbalance neurotransmitter, decrease of
serotonin, dopamine and norepinephrinne. So the patient need
psychopharmacology
PROBLEM RELATED TO THE PATIENT
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PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
To reduce 50% the symptoms :
- Always feel exhausted
- Easily tired
- Lost in interest
- No appatite
- Cant cocentrate
Response Remission Recovery
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RESPONSE PHASE
Target therapy :
50% decrease of symptoms
Emergency department
Diazepam 5 mg IV (sedation)Haloperidol Inj. 1 amp. IM
Maintenance
fluoxetine 1x10 mg per dayClobazam Tab 1x10 mg malam hingga 2 minggu lalu teppering
off (sedative)
Re-assess patient
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Target therapy :
100% remission of symptom
Inpatient management
1. Continue the pharmacotherapy: maintenance Fluoxetin 1x10mg &clobazam Tab 2x10 mg
2. 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 his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
REMISSION PHASE
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RECOVERY PHASE
Target therapy :
100% remission of symptom
Continue the medication, control to psychiatric
Rehabilitation :- Help patient to find a hobby,
- Help patient to interact normally with her
family and neighbor
- Family education
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