WILA
WILA FAJARIYANTIKA
FAJARIYANTIKA
20110310129
20110310129
Supervisor :
dr. Sabar Parluhutan Siregar,
Sp.KJ
PATIENTS IDENTITY
Name
: Tn. M
Age
: 36 years
Religion
: Muslim
Address
: Magelang Tengah
Job
: not work
Marital Status : unmarried
Education Status : SD
PSYCHIATRIC HISTORY
CHIEF COMPLAINT
Angry and seizure
STRESSOR
Undifined
2010
Patient was brought to emergency department of RSJS
Magelang by his environment leader with weakness and
seizure history. Patient can get his seize anywhere.
When he got his seize he was unconcious. Patient feels
weak and didnt know nothing when he got it. Beside
that, patient tells that he can smeels kemenyan
everywhere. Patient cant walk and must use
wheelchair. He dont have any family after his mother
dead.
November 2015
Result
Normal range
Elevating the
head
Moving to supine
position on its
own
Sitting
No Valid Data
0-3 months
No Valid Data
3-6 months
No Valid Data
6-9 months
Standing
No Valid Data
9-12 months
Walking
No Valid Data
12-24 months
Climbing up the
ladder
Standing 1 foot /
jump
No Valid Data
24-36 months
No Valid Data
36-48 months3
Result
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Normal range
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24-36 months
36-48 months
Ability
Result
Normal
range
Oooh-aah
No Valid
Data
0-3 months
No Valid
Data
3-5 months
High-pitched sound
No Valid
Data
3-6 months
No Valid
Data
6-9 months
9-12 months
No Valid
Data
18-24 months
No Valid
Data
24-36 months
Result
Normal range
Reach out
Clap
Tidy up toys
There are
INTERMEDIATE CHILDHOOD
(3-11 YEARS OLD)
Psychomotor
Psychomotor (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on when
when patient
patient first
first time
time climbing
climbing the
the tree
tree or
or
play
play hide
hide and
and seek
seek games,
games, and
and if
if patient
patient ever
ever involved
involved in
in any
any
kind
kind of
of sports.
sports.
Communication
Communication (NO
(NO VALID
VALID DATA)
DATA)
There
There was
was no
no valid
valid data
data regarding
regarding patients
patients ability
ability to
to make
make
friends
friends in
in school,
school, and
and how
how many
many friends
friends patient
patient have
have during
during
her
her schooling
schooling period.
period.
Emotion
Emotion (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on patient
patient adaptation
adaptation under
under stress
stress
Sexual
Sexual Development
Development Sign
Sign and
and Activity
Activity (NO
(NO VALID
VALID
DATA)
DATA)
No
No data
data on
on when
when patient
patient first
first wet
wet dream,
dream, growth
growth hair
hair on
on
armpits,
armpits, growth
growth pubic
pubic hair,
hair, etc.
etc.
Psychomotor
Psychomotor (NO
(NO VALID
VALID DATA)
DATA)
No
No data
data if
if patient
patient had
had any
any favorite
favorite hobbies
hobbies or
or games,
games, if
if patient
patient
involved
involved in
in any
any kind
kind of
of sports.
sports.
Psychosocial
Psychosocial (( NO
NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on when
when and
and how
how patients
patients relationship
relationship with
with
different
different gender,
gender, if
if patient
patient ever
ever had
had any
any relationship
relationship with
with
opposite
opposite gender.
gender.
Communication
Communication (NO
(NO VALID
VALID DATA)
DATA)
No
No valid
valid data
data on
on how
how well
well the
the relationship
relationship between
between patient
patient
with
with parents
parents and
and other
other family.
family.
Emotion
Emotion (NO
(NO VALID
VALID DATA)
DATA)
No
No data
data if
if patient
patient ever
ever told
told friend
friend or
or family
family regarding
regarding any
any
problems
problems
No
No data
data if
if patient
patient attempted
attempted to
to break
break the
the rules
rules (truant
(truant school
school
PRESCHOOL
Physical
Physically active
Rule of Three: 3 yrs,3
ft, 33 lbs.
Weight gain: 4-5 lbs
per year
Growth: 3-4 inches
per year
Physically active,
cant sit still for long
Clumsy throwing balls
Refines complex
skills: hopping,
jumping, climbing,
running, ride
bigwheels and
tricycles
Improving fine motor
skills and eye-hand
coordination: cut with
scissors, draw shapes
3 3,5 yr: most toilet
Cognitive
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, cant
represent themselves in drawing till
age 4
Dont realize others have
different perspective
Leave out important facts
May misinterpret visual cues of
emotions
Receptive language better
than expressive till age 4
Social
Play:
Cooperative,imaginati
ve, may involve fantasy
and imaginary friends,
takes turns in games
Develops gross and
fine motor skills; social
skills;
experiment with social
roles;reduces fears
Wants to please adults
Development of
conscience:
Incorporates parental
prohibitions; feels guilty
when disobedient;
simplistic idea of
good and bad
behavior
Curious about her and
others bodies, may
Emotional
Self-esteem based on what
others tell him or her
Increasing ability to control
emotions;
less
emotional
outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right
and wrong
Self-esteem reflects opinions
of significant others
Curious
Self-directed in many activities
SCHOOL AGED
Physical
Cognitive
Slow, steady
growth: 3 -4
inches per year
Use physical
activities
to develop gross
and fine motor
skills
Motor &
perceptual
motor skills better
integrated
10-12 yr: puberty
begins for some
children
Social
Friendships are situation
specific
Understands concepts
of right and wrong
Rules relied upon to
guide behavior and play, and
provide child with structure and
security
5-6 yr: believe rules can
be changed
7-8 yrs: strict adherence
to rules
9-10 yrs: rules can be
negotiated
Begin understanding social roles;
regards them as inflexible; can
adapt behavior to fit different
situations; practices social roles
Takes on more responsibilities at
home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self
Emotional
ADOLESCENTS
Physical
Growth spurt:
Girls: 11-14 yrs
Boys: 13-17 yrs
Puberty:
Girls: 11-14 yrs
Boys: 12-15 yrs
Youth acclimate to
changes in body
Cognitive
Formal operations: precursors in early
adolescence, more developed in
middle and
late adolescence, as follows:
Think hypothetically: calculate
consequences of thoughts and
actions without experiencing them;
consider a number of possibilities and
plan behavior accordingly
Think logically: identify and reject
hypotheses or possible outcomes
based on logic
Think hypothetically, abstractly,
logically
Think about thought: leads to
introspection and selfanalysis
Insight, perspective taking:
understand and consider others
perspectives, and perspectives of
social systems
Systematic problem solving: can
attack a problem, consider multiple
solutions, plan a course of action
Cognitive development is uneven,
Social
Young (12 14):
Psychologically distance self
from parents;identify
with peer group; social status
largely related to group
membership; social
acceptance depends on
conformity to observable traits
or roles; need to be
independent from all adults;
ambivalent about
sexual relationships, sexual
behavior is exploratory
Middle (15 17):
friendships based
on loyalty, understanding,
trust; self-revelationis first step
towards intimacy; conscious
choices about
adults to trust; respect honesty
& straight for wardness from
adults; may become sexually
active
Morality: golden rule;
Emotional
Psycho-social task is identity
formation
Young adolescents (12-14):
selfconscious about physical
appearance and early or late
development; body image rarely
objective, negatively affected by
physical and sexual abuse;
emotionally labile; may over-react to
parental questions or criticisms;
engage in activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others values,
beliefs; forms identity by organizing
perceptions of ones attitudes,
behaviors, values into coherent
whole; identity includes positive
self image comprised of cognitive and
affective components
Additional struggles with identity
ADULTHOOD
Occupational
Basic Conflict
Important Events
Infancy
(birth to 18 months)
Trust vs mistrust
Feeding
Early childhood
(2-3 years)
Toilet training
Preschool
(3-5 years)
Initiative vs guilt
Exploration
School age
(6-11 years)
Industry vs inferiority
School
Adolescence
(12-18 years)
Social relationships
Young Adulthood
(19-40 years)
Intimacy vs isolation
Relationship
Middle adulthood
(40-65 years)
Generativity vs
stagnation
Maturity
(65- death)
Reflection on life
FAMILY HISTORY
GENOGRAM
PROGRESSION OF ILLNESS
SYMPTOMS
2010
ROLE
FUNCTION
2015
MENTAL STATE
Appearance
A men, appropriate to his age, wear complete
clothes, enough self care
State of Consciousness
Clear
Connection
a. Attention easily attained, sustained
concentration (+)
b. Attention easily attained, unable to sustained
concentration (-)
c. Difficulty to attention, unable to sustained
concentration (-)
Speech
Quantity
:
- Increase
Decrease
Quality
:
Decrease
BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Normoactive
Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic
Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
ATTITUDE
Cooperative
Non-cooperative
Indifferent
Apathy
Tension
Dependent
Infantile
Distrust
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excitement
Emotion
Mood
Dysphoric (+)
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Affect
Inappropriate
Appropriate
Restrictive
Blunted
Flat
Labile
Disturbance of Perception
Hallucination
Auditory
(-)
Visual
(-)
Olfactory
(+)
Gustatory
(-)
Tactile
(-)
Depersonalization (-)
Illusion
Auditory
Visual
Olfactory
Gustatory
Tactile
(-)
(-)
(-)
(-)
(-)
Derealisation (-)
Thought Progression
Quantity
Logorrhea
Talk active
Remming
Blocking
Mutism
Quality
Irrelevant answer (-)
Incoherence
(-)
Coherent
(-)
Flight of idea
(-)
Confabulasion
(-)
Verbigerasion
(-)
Preservasion
(-)
Poverty of speech(-)
Slow speech
(-)
Loosening of assosiasion (-)
Sound assosiasion
(-)
Circumstantiality
(-)
Tangential
(-)
Neologism
(-)
Word salad
(-)
Echolalia
(-)
Content of thought
Idea of Reference (-)
Delusion of Control(-)
Preoccupation
Obsession
Phobia
(-)
(-)
(-)
Form of Thought
Realistic (+)
Non Realistic
Dereistic
Autistic
Self control
: Good
Patient response to examiners question :
Good
Insight
Impaired insight (+)
Intellectual Insight
True insight
Level of education
: SD
General knowledge
: Bad
Orientation of time/place/people/situation
good/good/good/good
Working/short/long memory:
Good/Good/Good
Concentration
: Good
Writing and reading skills : Good
Ability to self care
: Good
PHYSICAL EXAMINATION
GENERAL PHYSICAL
EXAMINATION :
GENERAL APPEARANCE : COMPOS
MENTIS
VITAL SIGN
BP : 120/70 MMHG
HR : 96X/MINUTE
TO : 36O C
RR : 20X/MINUTE
lymph nodes
Thorax
Cor
: S1 S2 regular, murmur -, gallop Lung
: vesicular sound +/+, wh -/-, rh-/Abdomen : Flat, abdominal wall//chest wall,
normal peristaltic, tympany sound, tenderness -,
mass -, liver, spleen and kidney not palpable
Extremity : Warm acral, cappilary refill <2,
edema (-)
NEUROGICAL EXAMINATON
Interpretation :
Interpretation
NORMAL
Interpretation :
Mental
Mental status
status
Mood: Dhysporic
Insight: Impaired
Insight
Disturbance of
Perception:
Hallucination
Olfactory
Impairment
Impairment
Limited role
function
SYNDROME
Patient can get his seize
anywhere When he got his
seize he was unconcious.
Seizure since 7 years ago
He can smeels kemenyan
everywhere
syndrome organic
supposition
DIFFERENTIAL DIAGNOSIS
MULTIAXIAL DIAGNOSIS
PLANNING MANAGEMENT
Responsive Phase
Remission Phase
The target of therapy was 100% remission of
symptoms
Recovery Phase
PROGNOSIS
Quo
Quo
Quo
Quo
Quo
Quo
ad
ad
ad
ad
ad
ad
vitam
:: ad
vitam
ad bonam
bonam
sanationam
sanationam :: ad
ad bonam
bonam
social
social funtion
funtion :: dubia
dubia
THANK YOU