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Saturday 17th May 2014

REFLEXI KASUS
SUPERVISOR
dr. Nur Dwi Esthi,
Sp.KJ

Patient Identity

Autoanamnesis
Nama
: Bp. B
JK
: Laki-laki
Umur
: 24 tahun
Alamat
: Purworedjo
Pekerjaan
: Sekretaris
Status
: lajang
Alloanamnesis
Nama
: Bu. S
JK
: Perempuan
Umur
: 54 tahun
Hubungan
: Ibu

Alasan pasien dibawa ke RSJS


Magelang
Pasien berbicara sendiri, marahmarah tanpa sebab, tidak bisa tidur

Stressor

Pasien tidak menyelesaikan


kuliahnya karena bekerja

RPS
April 2014
Pasien dibawa ke RS
oleh keluarganya
karena pasien
marah tanpa sebab,
mudah tersinggung
dan merusak
barang-barang

Mei 2014
Pasien mulai
menunjukan gejala
berbicara sendiri,
marah tanpa sebab,
dan tidak bisa tidur

Pasien tidak pergi kerja


Pasien tidak
menggunakan waktunya
dengan baik
Pasien tidak
berkomunikasi dengan
orang sekitar
Pasien pernah
mondok selama
20 hari
Pasien tidak pergi kerja
Pasien tidak
menggunakan
waktunya dengan baik
Pasien tidak
berkomunikasi dengan

Day of Admission
17 Mei 2014
Dibawa ke RS
oleh ibunya

Pasien tidak control dan


tidak teratur minum
obat

Pasien dibawa dengan


keluhan :
Berbicara sendiri
Marah tanpa sebab
Tidak bisa tidur

Pasien tidak dapat melakukan


aktivitas sehari-hari
Pasien tidak menggunakan
waktunya dengan baik
Pasien tidak berkomunikasi
dengan teman/orang sekitar

Riwayat Psikiatrik
Pasien pernah mondok 20 hari
di RSJS Magelang

General
medical
history

Drugs and alcohol


abuse history and
smoking history

Head injury (-)


Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)

Drugs consumption (-)


Alcohol consumption (-)
Cigarette Smoking (+)

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)


Psychomotoric (NO VALID DATA)
- 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 (NO VALID DATA)
- 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

Communication (NO VALID DATA)


- There were no valid data on when patient started bubbling.
(6-9 months)
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 his mother, recognize his family
members.
- There were no valid data on when the patient first copied
sounds that were heard, or understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)


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 regarding patient psychosocial.
Communication (NO VALID DATA)
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)
No valid data on patients emotional.
Cognitive (NO VALID DATA)
No valid data on patients cognitive.

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 patients emotional.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school

Masa Dewasa
Riwayat Pendidikan
Pasien rajin ke kampus namun tidak menyelesaikannya.

Riwayat Pekerjaan
Pasien bekerja sebagai sekretaris di partai politik.

Status Pernikahan
Pasien belum menikah.

Riwayat Hukum
Tidak pernah berurusan dengan pihak berwajib.

Aktivitas Sosial
Sebelum pasien sakit, pasien adalah orang yang introvert.
Pasien banyak mengikuti kegiatan organisasi.

Eriksons stages of psychosocial


development
Stage

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

Riwayat Psikoseksual
Pasien menyadari dirinya seorang laki-laki, dan tertarik pada
lawan jenis. Perilaku sesuai dengan laki-laki.

Sosial-ekonomi
Skala ekonomi : cukup

Taraf Kepercayaan
Alloanamnesis: Dapat dipercaya
Autoanamnesis: Dapat dipercaya

FAMILY HISTORY
Pasien

merupakan anak ke-4 dari 4


bersaudara.

Tidak

ada riwayat gangguan jiwa di


keluarga (-)

Genogram

MALE

FEMALE

patient

Progression of Disorder
Symptom

Role Function

April
2014

May
2014

Status Mental
17 Mei 2014

Deskripsi Umum
Seorang laki-laki, sesuai umur, berpakaian
lengkap

Status Kesadaran
Jernih

Pembicaraan
kuantitas : Meningkat
kualitas : Menurun

BEHAVIOUR

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

ATTITUDE

Noncooperative
Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Emotion
Affect

Mood

Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed

Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of Perception
Hallucination

Auditory (+)
Visual (+)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)

Illusion

Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealization (-)

Thought Progression
Quantity

Logorrhea
Blocking
Remming
Mutism
Talk active

Quality

Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia

Content of Thought

Idea of Reference

Delusion of grandiose

Idea of Guilt

Delusion of Control

Preoccupation

Delusion of Influence

Obsession

Delusion of Passivity

Phobia

Delusion of Perception

Delusion of Persecution

Delusion of Suspicious

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion &

Delusion of Hipochondry

Delusion of magic-mystic

withdrawal
Thought of Broadcasting

Form of Thought
Realistic

Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium dan Kognitif

Level of education : Tidak pergi kekampus


General knowledge : Tidak dapat dinilai
Orientasi waktu : baik
Orientasi tempat : baik
Orientasi orang : baik
Orientasi situasi : baik
Working/short/long memory: Tidak dapat dinilai
Writing and reading skills : Tidak dapat dinilai
Visuospatial : Tidak dapat dinilai
Abstract thinking : Tidak dapat dinilai
Ability to self care : Tidak dapat dinilai

Impulse control
when examined
Self control: enough
Patient response to
examiners question:
bad

Insight
Impaired insight
Intellectual Insight
True Insight

Physical State
Consciousnes
Vital

: compos mentis

sign :
Blood pressure
: 135/80 mmHg
Pulse rate
: 92 x/mnt
Temperature
: Afebrile
RR
: 24 x/mnt

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 <2.

Neurological exam : not examined

RESUME

Seorang laki-laki, 24 tahun, sesuai umur


Datang dengan keluhan berbicara
sendiri, marah tanpa sebab, tidak bisa
tidur
Tidak dapat melakukan aktivitas seharihari, pasien tidak menggunakan
waktunya dengan baik, pasien tidak
berkomunikasi dengan orang sekitar

RESUME
Symptoms

Day of admission
Mental
Impairment
Status
-

talking to
himself
angry
without any
reason
unable to
sleep

Hyperactive

Attitude: non-cooperative,
infantile

Mood: Euphoric

Affect: blunted

Perception: Auditory, visual


hallucination

Thought Progression: talk


active

- Form of Thought: Nonrealistic


- Content of thought:
Delusion of grandiose
- Patients response to
question: bad
- Impaired insight

He cant do his
daily activity,
Poor utilization
of leisure time
He couldnt
socialize with
friends

Differential Diagnosis
F25.0 Schizoaffective disorder manic type
F31.2 Bipolar affective disorder, Manic
episodes present with psychotic
symptoms

Multiaxial Diagnosis
Axis I

Axis II :
Axis III:
Axis IV
Axis V

: F25.0 Schizoaffective disorder


maniac type
Z91.1 Disobeyed of medication
Z03.2 No Diagnose
No Diagnose
: didnt finish his college
because of his work.
: GAF admission 30-21

Problem related to the


patient
1. Problem about patients life
Patient couldnt manage scedule, he didnt finish
his college because he had to work as a secretary
in political party. He refuse to take medicine.
2. Problem about patients biological state
The simplest formulation of the dopamine,
serotonin and norepinephrine hypothesis of
schizoaffective posits that schizoaffective results
from too much dopaminergic, serotonin and
norepinephrine activity.

PLANNING MANAGEMENT
Inpatient (hospitalization)
To reduce 50% the symptoms :
talking to himself
angry without any reason
unable to sleep
visual and auditoric

hallucinations

RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Haloperidol
5mg i.m
Diazepam
10mg i.v
Maintance
Haloperidol 2x5mg
Lithium Carbonate 1x200mg
Re-assess patient

REMISSION PHASE
Target therapy :
100% remission of symptom
Inpatient management
1. Continue the pharmacotherapy: maintenance
Haloperidol 2x5mg and Lithium Carbonate
1x200mg
2. Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor,
get a new job, find a hobby to do his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

RECOVERY PHASE
- Continue the medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact normally
with his family and neighbor
Family education :
explain to the family about the mental
disorder and the treatment.
- Educate the family to support not to exile
the patient.
- Ask the family to monitor patient progress
and make sure the patient take medicine
Target
therapy : 100% remission of
as prescribe.
-

symptom within 1 year.