Morning Report

PRESENTASI KASUSSKIZOAFEKTIF TIPE MANIKDokter Pembimbing:Dr. Nur Dwi Esthi, Sp. KJ

Adil Hijri MuhammadM. GibranWandiAdhitya RachmanUNIVERSITAS MUHAMMADIYAH YOGYAKARTARSJP PROF. DR. SOEROJO MAGELANG

Patients IdentityName : Mrs. MAge : 50 years oldSex : femaleAddress : LamonganJob : Marital status : marriedEthnicity : JavaneseEducational status : Elementary SchoolIdentitas pengantar pasienName : Mr. NAge : 33 years oldSex : maleAddress : Tanggulangi, KebumenJob : social serviceMarital status : marriedEthnicity : JavaneseEducational status : D3Relation: Social Service

Alloanamnesis and AutoanamnesisMain complain:Wondering and rampage in the streetHistory of present illness:Patient was brought to RSJS by Social service due to wondering, laughing, giggling, talk to herself, and rampage and angry without any reason in the street and disturb neighboorhood. Patient is very sure that she is the big leader and king of the entire world, who is rule, lead, and command people all around the world, and could know everythings what people doing, and she proud of herself, sure that all of prophet are her employeed. Patient always hear sounds that always praised her, and she is so sure thats came from her people. Patient is sure that she is always get wahyu directly from the God, enter to her mind. Patient is sure that she has been live for 500 centuries. Patient always feel happy and proud to herself because she is the most powerfull woman in the world.According to information from social service, she started looks abnormal since 3 years ago. She often looks sad, pull herself from social interaction, quit from her work as farmer and has tendency to kill herself. But recently, she show symptomps oppositely than before. Her family were so shame and could not hold any longer to deal with her condition and started to ignore her.

History of Past IllnessPsychiatric illness There is no history of pcychiatric illness. General medical illnessThere is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalizationSubstance abuseThere is no history about alcohol use, drug abuse or smoking .

Progression of Illness

SymptomsRole Function

2011Feb2015

Family HistoryThere is no history of psychiatric illness in her family.There is no history of high fever, seizure, head trauma, or any other serious illness which needs hospitalization

GENOGRAM

History of Personal LifePrenatal and perinatalThere was no valid data in patients prenatal and perinatal aspect, such as :Patients mothers age and condition when she was pregnantPatients mothers delivery history and patients perinatal condition. Patients immunization status

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)PsychomotorNo valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports.PsychosocialNo valid dataCommunicationNo valid dataEmotionNo valid dataCognitiveNo valid data.

History of Personal LifeLate childhood and teenage phase (11-18 years old)PsychomotorNo valid data if patient had any favorite hobbies or games, if patient involved in any kind of sports.PsychosocialNo valid dataCommunicationNo valid dataEmotionNo valid dataCognitiveAfter graduating from elementary school, patient did not go to school anymore

History of Personal LifeAdulthood phase (18 years old-now)EducationalPatient graduated from elementary schoolOccupationalPatient had housewife.Marital statusPatient has got married.CriminalShe has no criminal historySocial activityPatient was a resident of pondok pesantren and sometimes interated with other resident.Current situationPatient live alone.

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 life

General physical examinationGeneral appearance: she looks in good statusVital sign: BP: 130/85 mmHgHR: 118x/mto: afebrisRR: 24x/m

General physical examinationHead : normocephali, mouth deviation (-)anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax:Cor : S1 S2 regular, murmur -, gallop Lung : vesicular sound +/+, wheezing -/-, ronchi-/-Abdomen : flat, abdominal wall//chest wall, normal peristaltic, tympany sound, tenderness -, mass -, liver, spleen and kidney not papableExtremity : Warm acral, capp refill