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Saturday, 21st of March 2015Evening shiftMORNINGREPORTSupervisor:dr. Sabar P. Siregar, SpKJName: Mrs. TYTAge: 28 years oldGender: FemaleAddress: PurwokertoOccupation: UnemployedMarriage Status : MarriedReligion : MoslemLast Education : D3

Patients IdentityAlloanamnesis was conducted to:Name : Mr. BAge : 59 years oldSex : MaleAddress : PurwokertoJob : TeacherMarital status : MarriedEthnicity : JavaneseRelation: FatherGUARDIAN IDENTITYPatient was brought to the hospital by her father because he was rampage, full with anger with no reason, and threw things since 6 years ago.

The reason patient was brought to the hospitalBeing raped by her boyfriend that soon to be her husband at 2013.Being lied by her husband that her husband has been married and already have three children at 2014, because of that they dont live together anymore.StressorProgression of Illness2009 (6 years ago)Patient cant continued her formal education to bachelors degree because there was no education program that supported it. Since that time, patient began to angry easily, rampage if her demand not fulfilled, threw things because patient didnt feel comfortable with the noisy voices that disturbed her when she was alone, awake, or totally arousal, and saw her aunt shadow that had been passed away. Patient can ate, took a bath without any command, difficult to fell asleep because of that noisy voices, shut herself in her home, didnt interact with others, but patient had interest in learning English by attending english course. Then, patient was brought to the psychiatrist, she was given medicine and she was controlled routinely to the psychiatrist. According to her mother, patient was only took medicine at night because she didnt like feel sleepy all day long.Patient always got angry if her demand was not fulfilled, threw things, rampage, heard noisy voices frequently that disturbed her when she was alone or being together with her family, saw her aunt shadow that has been passed away..Patient can ate and took a bath by herself, difficult to fell asleep because of that disrupting voices in her ears, shut her self in her home, and didnt interact with her neighbors.Patient still took her medication and controlled to the psychiatrist routinely. 2010-2012Patient always got angry if her demand was not fulfilled, threw things, rampage, heard noisy voices frequently that disturbed her when she was alone or being together with her family, saw her aunt shadow that has been passed away. Patient said that her boyfriend brought her to the hotel, they did sexual intercourse without her consent. It was happened frequently. After that, she got pregnant before married.Patient can ate and took a bath by herself, difficult to fell asleep because of that disrupting voices in her ears, shut her self in her home, and didnt interact with her neighbors.Patient didnt want to take any medication, because she was bored and felt pressure because she must take a medication every day. 20132014Patient got married at January 2014, when she was 12 weeks pregnancy, but then she knew that her boyfriend already married and had 3 children. She was disappointed with her boyfriend then they didnt live together anymorePatient always got angry if her demand was not fulfilled, threw things, rampage, heard noisy voices frequently that disturbed her when she was alone or being together with her family, saw her aunt shadow that has been passed away. Patient was afraid with her sister because her sister always hit her when she was pregnant.Patient ate, took a bath without any command, patient was difficult to fell asleep because of that disrupting voices in her ears, shut her self in her home, and didnt interact with her neighbors.. Because her condition became worse, she was hospitalized for 1 weeks in RSUD Banyumas. After that, she always controlled to the psychiatrist routinely and took the medicine regularly.Patient gave birth a baby boy with cesarean section. She cant produce any breast milk, so the baby was given baby formula. The symptoms still appeared but still the same, such as got angry easily when her demand didnt fulfilled, threw things, heard voice with no source, saw her aunt shadow, and asking for unimportant stuffs (like as bought 1 clothes a day, want to have a car). Her shopping behavior became worse day by day. Patient felt that her neighbor can read her mind, she was being controlled by other person outside, she also said that the news in TV broadcasted her mind, and when she watched TV news about jail, she felt like the polices wanted to arrest her and be on the shelf.Patient ate and took a bath without any command, difficult to fell a sleep, cant take care of her son, just stayed at home, didnt want to interact with others, like for playing her gadget, and watching TV all day long.

August 2014 (8 Months before admission)Patient was rampage, got angry easily,.. Patient heard a noisy voices from a man and woman that asked Angkat tangan lo frequently when she was awake, began to sleep, or being alone. The voices was threatened her. She also heard voice that seduced her. Patient saw her aunt shadow that had been passed away. Patient felt that her neighbor can read her mind, she was being controlled by other person outside, she also said that the news in TV broadcasted her mind, and when she watched TV news about jail, she felt like the polices wanted to catch her and brought her to the jail. Patient said that she was afraid with her neighbor.. Patient like for buying unimportant things from a clothes a day until car. Her shopping behavior became worse day by day.

September 2014-february 2015Patient ate and took a bath without any command, difficult to fell a sleep, just stayed at home, cant take care of her son, didnt want to interact with others, like for playing her gadget, and watching TV all day long. Patient have an interest in learning Mandarin language, so she took the Mandarin course. Patient still took her medication and controlled to the psychiatrist routinely.

CONT..(SEPTEMBER 2014-FEBRUARY 2015)1 day before admissionPatient was rampage, got angry easily, and threw the powder bottle away because her son was crying asked for milk. Patient threw stones to her neighbor house because she felt disrupted. Patient heard a noisy voices from a man and woman that asked Angkat tangan lo or seduced her frequently when she was awake, began to sleep, or being alone. The voices was threatened her. Sometimes, patient saw her aunt shadow that had been passed away. Patient felt that her neighbor can read her mind, she was being controlled by other person outside. She also said that the news in TV broadcasted her mind, and when she watched TV news about jail, she felt like the polices wanted to catch her and brought her to the jail. Patient said that she was afraid with her neighbor.. Patient like for buying unimportant things from a clothes a day until car. Her shopping behavior became worse day by day. Patient ate and took a bath without any command, difficult to fell a sleep, just stayed at home, cant take care of her son, didnt want to interact with others, like for playing her gadget, and watching TV all day long. Patient still took her medication, but it didnt help anymore.

Cont.. (1 day before admission)Psychiatric IllnessPatient has a history of psychiatry illness. Patient was hospitalized in RSUD Banyumas at 2014 for one week.General Medical IllnessPatient has no general medical illnessSubstance AbuseSmoking (-), alcohol (-), NAPZA (-)History of Past IllnessFamily HistoryThere is no history of psychiatric illness in his familygenogramMale

Female

Patient

Living together

Died

Progression of IllnessRole of FunctionSymptom200920132014March 2015Prenatal and Perinatal HistoryEarly Childhood PhaseIntermediate ChildhoodLate ChildhoodHistory of Personal LifeThe patient was born with bidan, normal deliveries, an expected pregnancy, and her condition right after she was deliveredPRENATAL AND PERINATALDEVELOPMENTAL HISTORY (GROSS MOTORIC)AbilityResultNormal RangeElevating the headUnidentified0-3 monthsMoving to supine position on its ownUnidentified3-6 monthsSittingUnidentified6-9 monthsStandingUnidentified9-12 monthsWalkingUnidentified12-24 monthsClimbing up the ladderUnidentified24-36 monthsStanding 1 foot/jumpUnidentified36-48 months2222 DEVELOPMENTAL HISTORY (FINE MOTORIC)AbilityResultNormal RangeHolding a pencilUnidentified3-6 monthsHolding 2 objects at the same timeUnidentified6-9 monthsPiling 2 cubesUnidentified9-12 monthsInserting objects into containerUnidentified12-18 monthsRolling a ballUnidentified18-24 monthsDoodlingUnidentified24-36 monthsWearing shirtUnidentified36-48 months23DEVELOPMENTAL HISTORY (LANGUAGE)AbilityResultNormal rangeOooh-aahUnidentified0-3 monthsTurning toward the soundUnidentified3-5 monthsHigh-pitched soundUnidentified3-6 monthsVoice without meaning (mamama, bababa)Unidentified6-9 monthsCalling 2-3 syllables without meaningUnidentified9-12 monthsCalling 3-6 words that have meaningUnidentified18-24 monthsTalking at least with two wordsUnidentified24-36 monthsMentioning name, age, and placeUnidentified36-48 monthsOooh-aaahCalling 2-3 syllables without meaningCalling 3-6 words that have meaningThe name, age, place of24DEVELOPMENTAL HISTORY (SOCIAL & PERSONAL)AbilityResultNormal rangeKnow their motherUnidentified0-3 monthsReach outUnidentified3-6 monthsClapUnidentified6-9 monthsPlaying peek a booUnidentified6-9 monthsKnow their familyUnidentified9-12 monthsAppoint what he wants without crying or whiningUnidentified12-18 monthsTidy up toysUnidentified24-36 monthsPlaying with friends, follow the rules of the gameUnidentified36-48 months25History of Personal LifePrenatal and perinatal

Patient was wanted and planned by her parents.Patients mother was 27 years old during pregnancy and labor, and had no illnessPatient was delivered by normal labor, and by traditional birth attendantsPatient consumed pure breast milk for 6 months History of Personal LifeEarly childhood phase (0-3 years old)PsychomotorThere was no valid data in patients psychomotor aspect (such as tilting the body, supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop up object, holding pencil and pilling up two objects)PsychosocialThere was no valid data in patients psychosocial aspect (such as replying to smile, smiling when seeing interesting object, playing cilukba, knowing her family members and pointing what she wanted without crying)CommunicationThere was no valid data in patients communication aspect (such as bubbling, cooing, making sounds without meaning, telling 2-3 syllables without meaning and calling mama/papa)EmotionThere no valid data in patients emotion aspect (such as when patient playing, frightened by strangers, starting to show jealousy or competitiveness towards other, and toilet training)Patient didnt pee or defecate in her pants when she was two years oldCognitiveThere was no valid data in patients cognitive aspect (such as copying sounds that she heard for the first time and understanding simple orders)History of Personal LifeIntermediate childhood phase (3-11 years old)PsychomotorThere is no valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.PsychosocialThere was no valid data in patients psychosocial data (such as developing initiative capacity, seeking for socialization, starting social interaction with others, developing self worth in owns abilities and competitive capacity).CommunicationThere is no valid data on patients communication data (ability to communicate with same age friends/peers, and express needs and wants).EmotionThere is no valid data on patients emotion data (such as ability to experience physiologic response due to emotion)Cognitive Patient went to elementary school at 6 years old. And she could follow all her school program and study properly.History of Personal LifeLate childhood and teenage phase (11-18 years old)PsychomotorThere is no valid data on patients psychomotor data (such as favorite activities or games, if patient involved in any kind of sports). Psychosocial Patient was an introvert person and she always choose for her friends.CommunicationThere is no valid data in patients communication data (ability to interact with peers others, ability to discuss subjects and question, tolerate opposite opinions)EmotionThere is no valid data in patients emotion data (ability to control physiologic response due to emotion; such as palpitation, increased sweating when angry)CognitivePatient graduated from her senior high school.

History of Personal LifeAdulthood phase (18 years old-now)EducationalPatient finished her senior high school and continue her education to college as an secretary and graduated as D3 with cum laude. Patient has interest in learning the other language as English and Mandarin.OccupationalNot employeeMarital statusPatient was siri marriage at 2014, but then they didnt live together. Patient has 1 son who is 8 months old. Patient cant produce breast milk, so her son was given baby formula.CriminalShe has no criminal historyCurrent situationPatient lives with her parents and her baby boy.Eriksons Stages of Psychosocial DevelopmentStageBasic ConflictImportant EventsInfancy (birth to 18 months)Trust vs mistrustFeeding Early childhood (2-3 years)Autonomy vs shame and doubtToilet trainingPreschool (3-5 years)Initiative vs guiltExplorationSchool age (6-11 years)Industry vs inferioritySchoolAdolescence (12-18 years)Identity vs role confusionSocial relationshipsYoung adulthood (19-40 years)Intimacy vs isolationRelationshipMiddle adulthood (40-65 years)Generativity vs stagnationWork and parenthoodMaturity (65- death)Ego integrity vs despairReflection on lifeAppearanceA female, appropriate for his age, wear complete clothes, good self grooming,

State of ConsciousnessNeurological: Clear (compos mentis)Psychological: UnclearSocial: Impaired

SpeechQuantity : DecreaseQuality : DecreaseMENTAL STATE (MARCH 21ST 2015)Disturbance of PerceptionDepersonalisation (-)Derealisation (-)Thought ProgressionIdea of referencePreoccupationObsessionPhobia Delusion of persecutionDelusion of referenceDelusion of enviousDelusion of hipochondryDelusion of magic-mysticFantasyContent of thoughtDelusion of grandioseDelusion of controlDelusion of influenceDelusion of passivityDelusion of perceptionThought echoThought insertionThought withdrawalThought broadcastingCant be assessed

38RealisticNon RealisticDereisticAutisticForm of Thought Level of education: GoodGeneral knowledge: GoodOrientation of T/P/P/S: GoodWorking/short/long memory: GoodWriting and reading skills: GoodAbility to self care: GoodSensorium and CognitionOrientation T/P/P/S :Good/Good/Good/GoodorientationExaminationMarch 21st , 2015Conciousness: Compos mentis

Vital Sign:- Blood pressure: 100/60 mmHg- Pulse rate : 75x/min- Temperature : 36,5oC- Respiration rate: 19x/minPHYSICAL EXAMINATIONGeneralist statea. Head: Normocephali, mouth deviation (-)Anemic conjungtiva (-/-), icteric sclera (-/-), pupil isocoreb. Neck: Normal, no rigidity, no palpable lymph nodes, meningeal sign (-)c. Thorax:Cor: S1-S2 regular, murmur (-), gallop (-)Pulmo: Vesicular sound +/+, wheezing -/-, ronchi -/-d. Abdomen: Flat, abdominal wall//chest wall, normal peristaltic, tympany sound, tenderness (-), mass (-), liver, spleen, and kidney not palpablee. Extremities: Warm acral, capp refill