Professional Documents
Culture Documents
NON PSYCHOTIC
SUPERVISOR:
dr. Sabar P. Siregar, Sp. KJ
There was no valid data about prenatal history and mother pregnancy and
delivery, length of pregnancy, spontanity and normality of delivery, birth
trauma, whether the patient was planned or wanted, and also any birth
defect, how mother’s condition, and who was help of labor.
There was no valid data about the condition of patient when she was born
such as activity (muscle tone), pulse, grimace (reflex irritability), appearance,
and respiration (APGAR score)
There was no valid data about feeding habits of patient, is it breast feed or
bottle feed, was he having any eating problem.
Developmental History (Gross Motoric)
Psycho-social task is identity formation All of the problems listed in school age
Young adolescents (12-14): selfconscious about section
physical appearance and early or late development; Identity confusion: inability to trust in self to be a healthy adult;
body image rarely objective, negatively affected by expect to fail; may appear immobilized and without
physical and sexual abuse; emotionally labile; may Direction
over-react to parental questions or criticisms; engage Poor self esteem: pervasive feelings of guilt, self-criticism, overly
in activities for intense rigid expectations for self, inadequacy
emotional experience; risky May overcompensate for negative selfesteem by being
behavior; blatant rejections of narcissistic,
parental standards; rely on peer unrealistically self-complimentary;
group for support grandiose expectations for self
Middle adolescents (15-17): May engage in self-defeating, testing, and aggressive, antisocial,
examination of others’ values, or impulsive
beliefs; forms identity by organizing perceptions of behavior; may withdraw
ones attitudes, behaviors, values into coherent Lack capacity to manage intense
“whole”; identity includes positive self image emotions; may be excessively labile, with frequent and violent
comprised of cognitive and affective components mood swings
Additional struggles with identity May be unable to form or maintain
formation include minority or biracial status, being an satisfactory relationships with peers
adopted Emotional disturbances: depression,
child, gay/lesbian identity anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
Adulthood
Educational History
– She entered elementary school when she was six
years old. She graduated from elementary school
and continue her study to junior high school but
she didn’t continue her study to senior high school.
– There is no valid data about patient school history,
her prestation, relationship with teachers, favourite
studies. There is also no valid data about patient’s
participation in sport and hobbier, his attitude at
school, how many her friends, social popularity,
participation in group activities,
Psychosexual History
• Patient’s psychosexual history is appropriate to his
gender. The patient realizes that he is male and she
behaves according to his gender. She prefer to play with
peers female friends. There is no valid data about the
first time she attracted to male.
Genogram
Validity
• Alloanamnesis : Valid Data
• Autoanamnesis : Valid Data
September
2015
Role of Function
Mental State (September 13th 2015, 12.30 p.m)
Appearance
A female that inappropriate to her age, weared
completely clothes and had poor self care
State of Consciousness
Clear
• Connection of psychic
Attention easily attracted, unable to sustained
concentration (+)
BEHAVIOUR
Mannerism
Hypoactive Psychomotor
Automatism agitation
Hyperactive
Bizarre Compulsive
Echopraxia
Command Ataxia
Catatonia
automatism
Active negativism Mimicry
Mutism
Cataplexy Aggresive
Acathysia
Stereotypy Impulsive
Tic
Abulia
Somnabulism
ATTITUDE
Non-cooperative Passive
Infantile
Indiferrent negativism
Distrust
Apathy Catalepsy
Labile
Tension Cerea flexibility
Rigid
Dependent Excitement
Speech
• Quantity
Decrease (+)
• Quality
Decrease (+)
Emotion
Mood Affect
• Appropriate
• Dysphoric • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
Disturbance of Perception
Hallucination Illusion
• Auditory • Can’t be assessed
• Visual
• Olfactory
• Tactil
• Can’t be assessed
Derealisation can’t be
Depersonalisation can’t
assessed
be assessed
Thought Progression
Quantity Quality
• Irrelevan answer
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Confabulation
• Mutisme • Poverty of speech
• Talkative • Slow speech
• Loosening of association
• Neologisme
• Circumtansiality
• Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
Content of thought
Idea of Reference Delusion of Grandiose
• Realistic
• Non Realistic
• Dereistic
• Autistic
Sensorium and Cognition
Vital sign:
- Blood pressure : 120/70 mmHg
- Pulse rate : 84 x/min
- RR : 20x/min
- Temperature : 36,5o C
Review System
a. Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
b. Neck : normal, no rigidity, no palpable lymph nodes
c. Thorax :
Cor : S1 S2 regular, murmur -, gallop -
Lung : vesicular sound +/+, wheezing -/-, ronchi-/-
d. Abdomen :
Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness -, mass -, liver, spleen and
kidney not papable
e. Extremity : Warm acral, capp refill <2”, edema (-)
Neurogical Examination
Physiological reflex (Not asessed)
Upper extremities: biceps reflex , triceps reflex ,
brachioradial
Lower extremities: patella reflex , achilles tendon reflex
Motoric examination
Normal movement, good coordination, normal strength
Neurological Status
• Motorik : Normotonus, good coordination of movement
Her father also said she often confused. Her dad also said that she
experienced this complaint more than 18 years ago, often recurrent
and became heavy since 2 months ago. She also often disconnected
when spoken to her. She was always slow and just smiled when
giving an answer.
The patient's father began to realize that more and more patients are often
confused and long when answering when asked, and the patient looks gloomy.
And sometimes like children who like to play with water and soap. Since the
patient is getting harder to get along with the neighbors.
In 2013 the patient re-experiencing strange behavior. Patients suddenly lash out and
slammed the door slam, brought to the smart people do not change, eventually treated
in mental hospital for 2 months with a diagnosis of paranoid schizophrenia.
Patients condition improved but the patient is getting closed. do not want to clean the
house, it is difficult if asked, and all the housekeeping was done by his mother and
who take care of children is her husband. Now the patient said she was sad. Often
forgotten, sleep disorders and lazy and tired quickly want why doing. Since the last 2
months paien was in his parents' home and feel embarrassed to meet a child, husband
and in-laws.
SYNDROME FINDINGS
Syndrome of mental Schizoid personality
Syndrome of depression
retardation disorder
•Less visual and verbal •Less able to express
contact warmth, softness
•Mood dysphoric •Abulia
•Loss of excitement keada others
•Infantile •Schizoid personality
•Reduce energy, •Poor idea
lackness disorder
•Remming •Almost always
•Decrease of •Less concentration
concentration choose their own
Autism activities conducted
•Sleep disturbance •Early onset (<18 years
•Less of self confidens •Not have a close
old) friend or a close
•Depresion syndrom personal relationship
•Adaptive behavior less
•Useless free time
•Function diminished role
•Poor self care
THERAPY MANAGEMENT PLANNING
Hospitalization • No indication