CASE BASED DISCUSSION

KASUS PSIKOTIK

Oleh:
Abdul Roni 012116303
Cheilia Intan F 012116352
Indah Dwi A 012116415
Lutfan Adi P 012116436
Meta Azalia 012116450
Muhendra Ragah S 012116441
Rizky Ananda P 012116513
Ajilia Sehana P 30101206581
Estika Harum J P 30101206616
Karina Apriliana P 30101206654

Pembimbing:
dr. Sabar P. Siregar, Sp.KJ

KEPANITERAAN KLINIK ILMU KESEHATAN JIWA

RSJD PROF DR SOEROYO MAGELANG
FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2016
 I. PERSONAL INFORMATION
Patients identity
Name : Mrs. E
Place of birth : Magelang, May 03 1955
Age : 61 years age
Address : Magelang
Gender : Woman
Religion : Moslem
Etnic : Javanese
Marital status : Widow
Occupation : none
Education : Senior High School
Date of brought to hospital : 0ct 08 2016

II. PSYCHIATRIC EXAMINATION

a. Primary Problem
Patient was brought to emergency room in Prof. Dr Soerojo Magelang because of
Agitation.
b. History of Present Illness
History present illnes was taken from alloanamnesis to patients brother and niece
Friday, October 28 th 2016
Name : Mr. D E
Sex : Male
Age : 51 years old
Address : Secang, Magelang
Occupation : Employer
Relation : Young Brother
Intimacy : Close

Name : Mrs. Y
Sex : Female
 Age : 35 years old
Address : Rejowinangun selatan Magelang
Occupation : maid
Relation : niece
Intimacy : Not so close

Alloanamnesis
Patient was brought to Emergency RSJS Magelang by her brother with the
main problems iritated, wandered around the house, talking to heer self, and she
didnt want to take a shower sice 7 days before admission. Before this happened
patient treated in RSJS Magelang about twice with same problems.
Patient lived and worked in Jakarta as a maid. She lived with her husband and
3 childs. More or less 7 years ago, patient admited that her husband had cheated with
one of her family so she decided to took a divorce and lived in boarding hause. Since
that moment patients behaviour changed, like she didnt want to take a shower,
collected an unused goods, talking o herself and talked dirty words.
About six years ago, patient came back to Magelang with her brother and
treated in RSJS Magelang and because her economics problem patient finished her
treatment in RSJS Magelang. After she got her treatment she took her medicine and
control frequently. One years before patient felt that she was recovered and didnt
want to take her medicine. So she began to worked as a maid in Jakarta. After one
year patients problems appeared and worstening that caused the patient got kicked
out from her houseboard. So, she became a patient again in RSJS Magelang about
one month. Her family said she didnt take her medication frequently because she
was wishpered not to take her medicine. 3 weeks before patient went back to RSJS
Magelang with the same problems.

Autoanamnesis

Patient said that she came to RSJS Magelang with her brother. She felt more
secured if she came to RSJS Magelang, if she lived in her house she felt that
someone was trying to chased her and think that someone tried to killed her. Beside
that, she felt that every body around her can talking about her on her back. Patient
said heard a man wishpered and command her not to take a shower, not to take her
medication and eat a stink from her garbage. If patient tried to deny the whisper
 patient felt that she can die immidiately. Patient often saw something that can eat
people like VCD or TV. Patient also thought that so many spirit around her that
accompany her in her grave.

c. History of Past Illness

1. Psychiatry
She had been admitted to hospital before with the same symtomps
2. Medical
She did not have any history medical desease or head injury
3. Substain abuse and smoking
She did not have history of smoke , drugs and alcohol consumption.
d. Hystory of Personal Data
i. Prenatal and Post Natal Periode
There were no valid data about his mother during pregnant period, like :
Health
Disease
Smoke habits
Drugs
Alcohol
There were no valid data about his birth, like :
Gestational age
Weight
Length
ii. Early childhood phase (0-3 years old)
1. Psychomotoric (No Valid Data)
There were no valid data on which age patient
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 his hand(3-6 months)
putting everything in his mouth(3-6 months)
 2. 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 play, nor playing
claps with others (6-9 months)
3. Communication (No Valid Data)
There were no valid data on when patient started bubbling. (6-9 months)
4. 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.
5. 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.
iii. Intermediate Childhood Phase (3-11 years old)
1. Psychomotoric (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.
2. Psychosocial (No Valid Data)
No valid data regarding patient psychosocial.
3. 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.
4. Emotion (No Valid Data)
No valid data on patients emotional.
5. Cognitive (No Valid Data)
No valid data on patients cognitive
iv. Late Childhood and Teenage Phase (11-18 years old)
1.Sexual development signs & activity
No valid data on patients sexual development
2.Psychomotor
 No data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.
3.Psychosocial
No valid data regarding patient psychosocial.
4.Emotional history
No valid data on patients emotional history.
5.Cognitive
Patient graduate from junior high school.
6. Communication
No valid data regarding patient ability to make friends at school and how
many friends patient have during his school period.
v. Adulthood Phase (>18 years old)
1. Occupational History : She work in jakarta as a maid since 1974
2. Marital Status : Patient has been married for 40 years.
3. Educational History : He graduated from Senior High School.
4. Religion : He was diligent and obidient in worship.
5. Social Activity : Before he was sick, he often socialized with his friends ,
neighbors and her family
6. Psychosexual : patient aware that she is a woman, behaviour appopriate as
a woman and she attracted to girl.
7. Current Livng Situation : She lives together with her niece.
8. Family History : Patient is second son from 2 siblings, and has one older
sister, The relationship with his sibling is fine, There is one family
withpsychiatry disorder in family history.
9. Social Economic History : moderate
10. Description of Illness
III. FAMILY HISTORY
Patient is second son from 2 siblings, and has one older sister.
The relationship with his sibling is not fine.
There is one family with psychiatry disorder in family history.
GENOGRAM

IV. MENTAL STATE

a. General Description
i. Appearance : A female, appropriate to her age, completely clothed,
enough self care
ii. State of Consciousness : clear
iii. Attention : easly attained, sustainable
iv. Speech
1. Quantity : Talk Aktive
2. Quality : Inkoheren
b. Bahaviour and Attitude
i. Behaviour
- Normoactive (+) - Cataplexy - Psikomotor
- Hypoactive - Stereotype agitation
- Hyperactive - Mannarism - Compulsive
- Echopraxia - Automatism - Ataxia
- Catatonia command - Agresive
- Active Negativism - Acathisia - Impulsive
 ii. Attitude
- Cooperative (+) - Distress - Indifferent
- Noncooperative - Labile (+) - Excitement
- Apathy - Rigid - Cerea Flexibillity
- Tension (+) - Passive negativism - Catalepsy
- Dependent - Stereotypic - Infantile

c. Mood and Affect

i. Mood
- Disphoric - Irritable
- Eutymic - Expansive
- Elevated - Agitation(+)
- Euphoric - Cant be assesed
ii. Affect
- Approriate - Flat
- Inappropriate (+) - Labile
- Restrictive - Stabile
- Blunted

d. Disturbance of Perception
i. Halucination
- Auditory (+) - Gustatory
- Visual (+) - Tactile
- Olfactory
ii. Illution
- Auditory - Gustatory
- Visual (+) - Tactile
- Olfactory
e. Thought
i. Thought of Progression
Quantity Quality
- Logorhea - Coherence - Poverty of speech
- Talk active (+) - Incoherence (+) - Slow speech
- Remming - Irrelevan answer (+) - Loosening
- Blocking - Flight of idea association
- Mutism - Convabulation - Tangential
- Sound association - Neologism
- Circumtanciality - Echolali
- Word of salad
ii. Content of Thought
- Deution of control (+) - Thought echo - Preocupation
- Delution of influence - Thought of - Obsession
(+) insertion - Phobia
- Delution of passivity - Thought of - Idea of reference
- Delution of magic (+) withdrawl (+)
- Delution of - Thought of - Delution of chasing
perception (+) broadcasting (+) - Delution of
- Delution of envious gradiousil
iii. Form of Thoght
1. Realistic
2. Non realistic
3. Dereistik
4. Autistik

f. Sensorium and Cognitive

i. Level of education :Senior High School
ii. General knowledge : good
iii. Orientation : good
1. Time : good
2. Place : good
3. People : good
4. Situation : good
 iv. Memory : good
v. Ability to read and write : Cannot assessed
vi. Ability of independent :Cannot assessed
g. Impulsive control when examined
i. Self control : bad
ii. Patient respon toward examination : bad
h. Insight : stage 1
i. Impaired insight (+)
ii. Intelectual insight
iii. True insight

V. INTERVAL STATE
a. Consciousness : compos mentis
b. Vital sign :
Blood pressure : 130/80 mmHg
Pulse rate : 103x/mnt
Temperature : 36,8 0C
RR : 20 x/mnt
c. Head : Normocephali, crepitation (-)
d. Eyes : Anemic conjungtiva (-), icteric sclera (-), exopthlamus (-), IOP
(N)
e. Neck : no palpable lymphnodes
f. Thorax :
Cor :
Inspection : Ictus cordis cant be seen
Palpation : Ictus cordis palpable on SIC V line
midclavicular sinistra
Percution : Cardiomegaly (-)
Auscultation: S1-S2 normal, murmur (-), gallop (-)
Lungs :
Inspection : symetric movement of the chest
Palpation : Fremitus normal , pain (-)
Percution : Sonor (+/+)
 Auscultation : Vesicular sound, wheezing (-/-), ronchi (-/-)
g. Abdomen :
1. Inspection : distension (-)
2. Auscultation : normal peristaltic sound
3. Palpation : epigastric pain (+) mass (-)
4. Percution : thympani, hepatosplenomegaly (-)
h. Extremity :
1. Warm, capillary refill time<2, edema (-)
2. Sianosis (-)

VI. NEUROLOGICAL EXAMINATION

a. Upper limb
i. Tonus : normotonus
ii. Motoric strenght : 5/5//5/5
iii. Physiologic Reflex : (+)
iv. Pathologic Reflex : (-)
b. Lower limb
i. Tonus : normotonus
ii. Motoric strenght : 5/5//5/5
iii. Physiologic Reflex : (+)
iv. Pathologic Reflex : (-)
c. Cranial examination
i. N.c.I : smelling impression good
ii. N.c. II : pupil reflect (+/+), isocoric (+/+)

iii. N.c. III, IV, VI :

iv. N.c. V : sensory facial (+)
v. N.c. VII : hipomimic ,symetric face, motoric: raise both eyebrow, frown
vi. N.c. VIII : hearing impression good
vii. N.c IX,N.c X : uvula in the middle (+), no disturbance of swallowing
viii. N.c XI : no disturbance in neck and shoulder movement
 ix. N.c XII : normal
d. Sensoric Examination
i. Pain and light touch sensorium:normal
ii. Passion sense : normal
iii. Stereognostic : normal
iv. Graphestetic : normal
v. Extination : normal
e. Range of movement
i. Carpal metacarpal : normal
ii. Metacarpal - phalangeal : normal
iii. interphalanx : normal
f. Meningeal sign
i. Kernig sign : (-)/(-)
ii. Brudzinsky I : (-)
iii. Brudzinsky II : (-)
iv. Brudzinsky III : (-)
v. Brudzinsky IV : (-)
vi. Brudzinsky V : (-)

VII. RESUME
A woman, 61 years old, appropriate according to her age, completely clothed, enough
self care.
Reason to be brought to hospital was because of agitation.
More or less 7 years ago, patient admited that her husband had cheated with one of
her famil so she decided to took a divorce and lived in boarding hause. Since that
moment patients behaviour changed, like she didnt want to take a shower, collected
an unused goods, talking o herself and talked dirty words.

VIII. SYMPTOMS
1. Psychotic
form of thought : non realistic and autistic
Impaired insight
2. Skizophrenia
halucination auditorik
 Halucination visual
Delusion of control
Delusion of perception
Delusion of influence
Thought of broadcasting
Delusion of magic mistic
Afect inapropriate
3. Paranoid
Delusion of reference
Delusion of persekutorik

IX. DIAGNOSTIC FORMULATION

Axis I
F.20.0 Skizofrenia Paranoid
Diagnostic criteria can be know by using diagnostic guideline based on PPDGJ
III
F.20.0 Skizofrenia paranoid :
Pedoman Diagnostik

Diagnostic Guideline In Patient

Memenuhi kriteria umum diagnosa Yes
skizofrenia
Sebagai tambahan :

- Halusinasi dan / atau waham harus

menonjol ;
a. Suara suara halusinasi yang yes
mengancam pasien ataumemberi
perintah, atau halusinasi auditorik
tanpa bentuk verbal berupa bunyi
peluit (whistling), mendengung
(humming), atau bunyi tawa
(laughing)
b. Halusinasi pembauan atau pengecapan no
 rasa , atau bersifat seksual, atau lain-
lain perasaan tubuh ; halusinasi visual
mungkin ada tetapi jarang menonjol
c. Waham dapat berupa hampir setiap yes
jenis , tetapi waham dikendalikan
(delusion of control), dipengaruhi
(delusion of influence) atau passivity
(delusion of pasivity), dan keyakinan
dikejar kejar yang beraneka ragam
adalah yang paling khas;
- Gangguan afektif, dorongan kehendak yes
dan pembicaraan , serta gejala katatonik
secara relatif tidak nyata/tidak menonjol

X. MULTIAXIAL DIAGNOSIS
Axis I : F.20.0 Skizofrenia Paranoid
Axis II : Z03.2 There is no diagnose
Axis III : None
Axis IV : Primary Support Group
Axis V : GAF 40-31
XI. PROBLEM RELATED TO THE PATIENT
Problem about patients mental state (psychology)
If patient lived in her house she felt that someone was trying to chased her and
think that someone tried to killed her.
Patient felt that every body around her can talking about her on her back
Patient said heard a man wishpered and command her not to take a shower, not to
take her medication and eat a stink from her garbage.
If patient tried to deny the whisper patient felt that she can die immidiately.
Patient often saw something that can eat people like VCD or TV, VCD can eat
people.
Patient also thought thatso many spirit around her thar accompany her in her
grave.
XII. PLANNING MANAGEMENT
a. Hospitalization
The patient must be hospitalized because has brought danger to other people
and to decrease the symptoms.
b. Respon Phase
The target of therapy is to decrease 50 % of symptoms emergency
- Injection of haloperidol 5 mg intramuscular
Patient was given typical group of antipsychotic agent to decrease the
positive symptom (Hallucination, delusion and illusion)
- Injection of diazepam IV
Patient was given diazepam for sedative effect and muscle relaxan
c. Remission Phase
The target of therapy is to decrease 100 % of symptoms
- Psychotherapy to patient which is supportive psychotherapy
In this case , patient is known hard to take medicine because of her
impaired insight of psychiatric illnes. So, in supportive therapy patient is
taught to take medicine regularly by giving her appreciation of her
determinity in taking medicine
- Psychoeducation to family
Tell her family about patients mental disorder and support patient in his
life. Family must remind patient to take medicine regulaarly and control to
psychiathric patients family also included in supportive psychotherapy
d. Recovery Phase
1. Tell to her family about mental disorder
2. Mental disorder is multifactorial cause (Biologic, Psychologic, social)
3. Mental disorder are biologically caused imbalance of chemical in the brain
that require medication for a long time
4. Treat the patient as she is do not excessive
5. Familly should be aware of the ability of patient is different from others
6. Assist patient if needed
7. Tell the patient in their life, there are people who love and care about her
XIII. PROGNOSIS
Factors affect prognosis
Family history of mental disorder negative Good
Marital state marriedGood
Economic state moderate Good
Premorbid personality unknown
Age of onset 54 years oldGood
Type of illnes chronicBad
Organic disease negativeBad

Ad vitam : ad bonam
Ad functionam : dubia ad malam
Ad sanationam : dubia admalam