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I. PATIENTS IDENTITY
Autoanamnesis Name Age Gender Address Occupation Marital status Last education Alloanamnesis Name Age Relation : Mrs. R : 39 years old : Female : Tangerang, Banten : unemployed : Married : Elementary school : Mr S : 40 years old : Husband
*Present History
1 weeks ago 6 months ago
Stop Working, the companys bankrupt. Patient become more quite, and often daydreaming. Patient easily got angry if somebody didnt full fill what she needed especially with her husband
Still working as a housewife,
Social life still good, but patient more spending her time in her house utilization of leisure time still good ; patient love to sewing and making clothes Self grooming still good; patient still eat well, and taking a bath daily
Patient become more often get mad. She even ran into her neighbor with carrying a knife. Patient become more quite, and sometimes crying especially when shes praying. Her husband sometimes said that shes talking to her self
Didnt work even as a housewife
Social withdrawal Poor utilization of leisure time Self grooming still good: patient still eat well and taking a bath daily
*Present History
Day of admission
Didnt want to work even as a housewife, Poor utilization of leisure time : patient spent lots of time with daydreaming Social withdrawal Self grooming still good ; patient still take a bath daily and eat well
Psychiatry history
Hypertension (-) Head injury (-) Convulsion (-) Asthma (-) Allergy (-)
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 (UNVALID DATA) There were not get important data on which age patient
started smiling when seeing anothers 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 (UNVALID DATA) There were not get important data on when patient started babbling. (6-9 months)
Emotion (UNVALID DATA) There were not get important data of patients reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards others and toilet training. Cognitive (UNVALID DATA) There were not get important data on which age the patient can follow objects, recognizing his mother, recognize her family members. There were not get important data on when the patient first copied sounds that were heard, or understanding simple orders.
Sexual development signs & activity (UNVALID DATA) No data on when patient experience menarche, hair on armpits and pubis, etc * Psychomotor (UNVALID DATA) No data if patient had any favourite hobbies or games, if patient involved in any kind of sports. * Psychosocial (UNVALID DATA) Patient had never been told family about patients friend. * Emotional (UNVALID DATA) not get important data on patients reaction on playing, scared, showed jealously or competitiveness * Communication (UNVALID DATA) not get important data on how well the relationship between patient with parent and his family.
PHASE
*ADULTHOOD
Educational History
Current Situation
she lived in jakarta with her husband, she had a harmonic life, and had been separated with her family by her choice.
Occupational history
Marital Status
Elementary School
had been married for 10 years but didnt had a child or never been pregnant before
Patient had introvert personality, but still had a good social life with the neighbours.
* Family history
Family history
*Patient is the 7th childs of 8 siblings. *Theres no psychiatry history in the family.
*Psychosexual History
* shes been married
for 10 years, but havent got a child yet and never been pregnant before. Her behavior is appropriate for female.
Genogram
*Progression of disorder
Symptom
August 2013
february 2014
Role function
Appearance
A woman, appropriate to her age, completely clothed, self grooming still good.
State of Consciousness
Clear
Speech
Quantity : decreased Quality : decreased
Behaviour
Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Strereotypy Mannerism Automatism
Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia
ATTITUDE
Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Active Passive
Infantile Distrust Labile Rigid Passive negativism Catalepsy Cerea flexibility Excitement
Emotion
Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile
Mood
Dysphoric Elevated Euphoria Expansive Irritable Agitation Cant be assessed
Disturbance of perception
Hallucination Auditory (+) Visual (+) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Depersonalisation (-) Illusion
Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)
Derealisation (-)
Thought progression
Quantity Quality
Irrelevan answer Incoherence Flight of idea Coherent Poverty of speech Loosening of association Neologisme Circumtansiality Verbigrasi Perseverasi Sound association Word salad Echolalia
Content of thought
Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Thought of Echo Thought of
Phobia
Delusion of Persecution Delusion of Reference Delusion of Envious Delusion of Hipochondry Delusion of magic-mystic
Insertion/withdrawal
Thought of Broadcasting Cant be assessed.
Form of Thought
: elementary : cant be assesed : cant be assesed : cant be assesed : not examined : not examined : not examined : good
Insight
Internal Status
Conciousnes : compos mentis Vital sign : Blood pressure : 100/70 mmHg Pulse rate : 80 x/mnt Temperature : afebris RR : 20x/mnt
RESUME
Symptoms Mental Status
Hypoactive Passive Coherent Remming Hallucination (+) auditory & visual Idea of reference Thought of withdrawal
Impairment
Poor utilization of leisure time Didnt want to work even as a housewife Social withdrawal self grooming still good
Differential Diagnose
F20.00 Schizofrenia Paranoid - F25.10 Schizoaffective depressive type - F32.30 Severe Depressive episode with psychotic symptoms.
Multiaxial Diagnose
Axis I Axis II Axis III Axis IV Axis V :F25.1 Schizoaffective depressive type :Introvert :none :Desire for having a child :GAF admission 40-31
*
Hospitalization
purpose
of hospitalization is to decrease the symptoms, so patient can handle herself, and not hurting people around her. Hospital treatment plans should be oriented toward practical issues of quality of life, role function and social relationships. To establish an effective association between patients and community support systems.
*PLANNING MANAGEMENT
Pharmacothisapy
For sedative
Psycho-education Educate the patient and family after medication: * Explain to patients family about mental disorder. There are many factors cause the symptoms. * Treat the patient according to the familys ability, dont demand the patient more nor less. * Help the patient when he needs it. * Education of the family to encourage communication and understanding.
*PROGNOSIS