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1. The patient is a 25-year old male who was brought to the hospital by health workers after being locked in his room for 5 years.
2. For the past 5 years, the patient has exhibited unusual behavior such as staying in his bedroom covered by a blanket, not speaking to anyone except when hungry, and waking up at night with no purpose.
3. The patient's father previously took him to a paranormal healer with no improvement in his condition. The patient requires assistance with basic tasks and has been socially withdrawn.
1. The patient is a 25-year old male who was brought to the hospital by health workers after being locked in his room for 5 years.
2. For the past 5 years, the patient has exhibited unusual behavior such as staying in his bedroom covered by a blanket, not speaking to anyone except when hungry, and waking up at night with no purpose.
3. The patient's father previously took him to a paranormal healer with no improvement in his condition. The patient requires assistance with basic tasks and has been socially withdrawn.
1. The patient is a 25-year old male who was brought to the hospital by health workers after being locked in his room for 5 years.
2. For the past 5 years, the patient has exhibited unusual behavior such as staying in his bedroom covered by a blanket, not speaking to anyone except when hungry, and waking up at night with no purpose.
3. The patient's father previously took him to a paranormal healer with no improvement in his condition. The patient requires assistance with basic tasks and has been socially withdrawn.
Arranged by: Cherish Idea Rahmayani Diva Oktavianita H Vivien Karina S Metiel Amigo P Tri Widianto
Supervisor dr. Sabar P. Siregar Sp.KJ
Pshychiatry Medical RSJ Prof. dr. Soerojo Magelang 2014 I. Patients Identity: Name : Mr. M Age : 25 years old Gender : Male Address : Wonosobo Occupation : Labourer Religion : Moslem Marriage Status : Single Last Education : Elementary school II. Alloanamnesis has been done by asking from: Name : Mr. M Age : 60 years old Relationship with patient : Father III. A. The reason of patient was brought to hospital Locked him self for 5 years, the health workers take him to hospital B. Present History 5 years ago (2009) Patient started to have unusual behavior He always stay at his bedroom and covered his body with blanket His father said that he looks like being shame He always looked down without doing anything He never talk to his parents except when he got hungry Sometimes he woke up at midninght and nothing to do When his friends came, he never want to meet them Impairment He didnt work Poor utilization of leisure time Social withdrawal He cant taking care of him self 3 years ago (2011) His father took him to paranormal for asking about his condition, paranormal gave the father a sewings and asked him to put in patients wrist, for knowing about why it could be happen but it didnt work Patients condition still the same, he just stayed at his bedroom and covered his body with blanket He always looked down without doing anything He never talk to his parents except when he got hungry Sometimes he woke up at midninght and nothing to do When his friends came, he never want to meet them Impairment He didnt work Poor utilization of leisure time Social withdrawal He cant taking care of him self Day of admision He always stay at his bedroom and covered his body with blanket His father said that he looks like being shame He always looked down without doing anything He never talk to his parents except when he got hungry Sometimes he woke up at midninght and doing nothing The health workers visited the village and found the condition. Then ask the parents to take him to RSJS Magelang Impairment He didnt work Poor utilization of leisure time Social withdrawal He cant taking care of him self, he didnt take a bath for 5 years He cant walk, his father must carry him up to move his body C. History of Illness 1. Psychiatric History :There was no psychiatric history before. 2. General medical history: Head injury (-) Hypertension (-) Convulsion (-) Asthma (-) Allergy (-) History of admission (-) 3. Drugs and alcohol abuse history and smoking history: Drugs consumption (-) Alcohol consumption (-) Cigarette Smoking (+) IV. Personal History A. Prenatal and Perinatal History Father forgot how gestational age when the child was born Father forgot how child birth age B. Early childhood phase (0-3 years old) Psychomotoric First time lifting the head (forgot) Rolling over (forgot) Sitting (forgot) Crawling (forgot) Standing (forgot) walking-running (forgot) holding objects in his hand(forgot) putting everything in his mouth(forgot) Psychosocial His father forgot of his childs development : 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) Communication His father forgot when the patient started saying words 1 year like mom or dad. (6-9 months) Emotion 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. (the father forgot about it) Cognitive There were no valid data on which age the patient can follow objects, recognizing his father and father, recognize his family members. (the father forgot about it) There were no valid data on when the patient first copied sounds that were heard, or understanding simple orders. (the father forgot about it)
C. Intermediate childhood (3-11 years old) Psychomotor No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports. (the father forgot about it) Psychosocial No valid data on patient interaction with his surrounding, no valid data on when patient first entered primary school, on how well patient handle separation from parent, how well he play with his new friend on first day school. (the father forgot about it) Communication (the father forgot about it) Emotional No valid data on patients adaptation under stress, any incidents of bedwetting were not known. (the patient never told about his life to his family) Cognitive He stopped school in third grade of elementary without any reason D. Late childhood & teenage phase Sexual development signs & activity No valid data on patients first experiece of wetdream (forgot) Psychomotor Patient had any favourite hobbies or games, if patients involved in any kind of sport (forgot) Psychosocial Patient had a good relationship with all of his friends Emotional No valid data on patients reaction on playing, scared, showed jealously or competitiveness Communication He has good communication with his parents E. Adulthood Educational History On elementary school he didnt continue his study, thre is no reason Occupational history He worked as a labourer and a good worker Marital Status Single (he never told his fathers about his love life) Criminal History No Social Activity Before he got the dissorder, he has a good relationship with family and friends Current Situation He lives with his father and father F. 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 G. Family History GENOGRAM
H. Psychosexual History Difficult to assessed No partner for now I. Socio-economic history Economic scale: low J. Validity Alloanamnesis : valid Autoanamnesis : no valid
K. Progression of Disorder
V. Mental State (Sunday, 23 rd February 2014) A. Appearance A male, appropriate to his age, completely clothed, smells bad B. State of Consciousness Stupor C. Speech Quantity : decreased Quality : cant be assessed D. Behaviour Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Stereotypy Mannerism Automatism Bizarre Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia E. Attitude Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Passive Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility Excitement F. Emotion Mood Dysphoric Euthymic Elevated Euphoria Expansive Irritable Agitation Cant be assesed Affect Appropriate Inappropriate Restrictive Blunted Flat Labile G. Disturbance of perception Hallucination Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cant be assesed Illusion Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cant be assessed H. 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 Verbigrasi Perseverasi Sound association Word salad Echolalia Cant be assessed I. Content of thought Idea of Reference Idea of Guilt Preoccupation Obsession Phobia Delusion of Persecution Delusion of Reference Delusion of Envious Delusion of Hipochondry Delusion of magic-mystic Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Delusion of Suspicious Thought of Echo Thought of Insertion/withdrawal Thought of Broadcasting Cant be assessed J. Form of thought Realistic Non Realistic Dereistic Autistic Cant be assessed K. Sensorium and Cognition Level of education : cant be assessed Orientation of time : cant be assessed Orientations of place : cant be assessed Orientations of peoples : cant be assessed Orientations of situation : cant be assessed Working/short/long memory: Not cooperative Writing and reading skills : Not cooperative Visuospatial : Not cooperative Abstract thinking : Not cooperative Ability to self care : Low L. Impulse control when examined Self control: low Patient response to examiners question: poor M. Insight Impaired insight Intellectual Insight True Insight Cant be assessed VI. Physical Examination Quantity Consciousnes : Composmentis GCS : E 4 V 5 M 6
Vital sign: Blood pressure : 120/90mmHg Pulse rate : 96x/m Respiratiry Rate : 20x/m Temperatur : afebris Head :Normocephali Anemic conjungtiva -/-, icteric sclera -/-, pupil isocore Neck :normal, no rigidity, no palpable lymph nodes Thorax Inspeksi : IC did not show Palpasi : normal Palpasi : normal Perkusi : Dull Auskultasi : S 1,2 Sound and normal Lung Inspeksi : Enlargement ICS (-), retraction (-), Palpasi : Sterm fremitus dextra = sinistra Perkusi : Resonance Auskultasi : Vesicular sound, wheezing -/-, ronchi-/- Abdomen Inspeksi : Flat Auskultasi : Normal peristaltic, tympany sound Perkusi : Timpani Palpasi : Pain (-) Extremity Ekstremitas Superior Inferior Capp refill, <2/<2 <2/<2 Warm acral +/+ +/+
Neurological exam : not examined VII. Resume of Admission Symptoms Always stay at bedroom and covered body with blanket Looks like being shame Looked down without doing anything Never talk except when he got hungry woke up at midninght and nothing to do
Mental Status Stupor Decreased quantity of speech Hypoactive Rigid Mutism Flat Non cooperative Passive negativism Disability Has not worked Has not taking care to his self Poor utilization of leisure time Social withdrawal Cant walk VIII. Differential Diagnosis F20.2 Catatonic Schizophrenia F32.2 Severe depression episode without psychotic symptoms F32.3 Severe depression episode with psychotic symptoms IX. Multiaxial Diagnosis Axis I : F20.2 Catatonic Scizophrenia Axis II : R46.8 delayed diagnosis of axis II Axis III : No diagnosis Axis IV : Unclear Axis V : GAF admission 30-21 X. Planning Management Hospitalization To establish self-care, quality of life, employment, and social relationships Pharmacotherapy Psycho-education XI. Response phase Emergency department Emergency Room: Typical antipsychotic: - Inj Haloperidol 5 mg IM - Inj Diazepam 10 mg IV Routine therapy Typical antipsychotic: Haloperidol 2 x 5 mg Suggest: - ECT - Physiotherapy Psychosocial Therapy Family-Oriented Therapies