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General Information

Name : Mrs. W
Age : 66 years old
Sex : Female
Address : Jatiluhur, Kebumen
Occupation : Former Government Officer
Marital status : Married
Ethnic background : Javanese
Prior Education : S1

Alloanamnesis
Name : Mr .A
Age : 44 years old
Sex : Male
Address : Jatiluhur, Kebumen
Relation : Son

I. Psychiatric Status
A. Chief Complaint (Alloanamnese)
Patient was confused and had communication problem

B. Present History
Patient was brought to the Prof. Dr. Soerojo Magelang Asylum with
chief complaint confused and had communication problem. 3 weeks ago
patient was dropped in a bathroom at her house on 24 April 2014. Her family
said that patient was dropped at 6 a.m and in conscious state. After the patient
dropped, she cant move her left extremities and fel weak, so her family bring
her to the hospital at Kebumen for 1 weak and had a medical treatment.

After 1 week patient had a medical treatment in Kebumen hospital,
patient was discharged in 1 May 2014. The patient family said that the patient
was confused and had communication problem since 3 weeks ago; everytime
her family try to coommunicate with the patient, patient cant reply the
question well and always talk inappropriate answer. Patient also cant sleep
well since 1 week ago and report says that she always talks by herself during
sleep time. Patient also easily angry with everyone. Patient cant walks by
herself and just laid on the bed, patient use pampers for toileting. She cant eat
by herself and need someone to feed her. Patient also loose her appetite. Due
to this problems, the patients family brought the patient to the RSJ Magelang
for further treatment.

C. Past Ilness
i) Psychiatrics
Patient had a psychiatric history in 1980. Her son told that in 1980, patient had
a depression to finish her education due to marriage business. Therefore, this story is
still unclear.
ii) Medical
Patient had no medical ilness history
iii) Drugs, Alcohol Abuse and Smoking History
Patient had no history of using drugs, alcohol and cigarrette.
D. Family History
1. Prenatal and Perinatal
Patient is the first child from six sibling.

2. Early childhood (0-3 years old)
There were no valid data on patients growth and development such as 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)
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).
There were no valid data on when patient started bubbling. (6-9 months)
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.
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.

3. Middle Childhood (3 -11 years old)
No valid data on when patients first time playing hide and seek or if patient
ever involved in any kind of sports.No valid data regarding patient psychosocial.
No valid data regarding patient ability to make friends at school and how many
friends patient have during his school period. No valid data on patients
emotional. No valid data on patients cognitive.
4. LATE CHILDHOOD & TEENAGE PHASE (11-18 years old)
No data on when patient starts menarche, ect. No data if patient had any
favourite hobbies or games, if patient involved in any kind of sports. No valid data
regarding patient psychosocial. No valid data on patients emotional. No valid
data regarding patient ability to make friends at school and how many friends
patient have during his high school period
5. Adulthood Phase
Patient is a former government officer. Patient was married and she never
affiliated with the army. Patient last education is graduated from degree. Patient is
a muslim. Patient is a kind person and has many friends. She live alone in the
house and she never committed a criminal act.
E. Psikosexual History
Patient is aware that she is female. Behaves and dresses appropriately for her
gender and also attract to opposite gender.

F. Fantasies and dreams
Patient doesnt have fantasies and dreams

G. Validity
Autoanamnese : Invalid
Alloanamnese : Valid













H. Genogram.




Male Female Patient

I. Deplication Of Ilness







1980 24 April 2014 14 May 2014
J. Mental State Examination
A. General Depiction

1. Appearance : Female, dressess as female, poor groomed
2. Consciousness : Neurologic : Compos Mentis
Psychologic : Clear
3. Speech : Quantity : Decreased
Quality : Decreased

4. Behaviour : Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

5. Attitude : Cooperative
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited
6. Physy Connectivity : 1. Attention easily attained, sustained
Concentration
2.Attention easily attained, unable to sustain
concentration
3.Difficulty in attained attention, unable to
sustain concentration
7. Mood and Affect
Mood : Dysthym
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Afffect : Inappropriate
Restrictive
Blunted
Flat
Labile

7. Perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)

Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-
Derealization (-)
8. Thought Proceess
Quantity
Logorrhea
Blocking
Remming
Mutism
Talk active
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
9. Thougt Content
Idea of Reference
Idea of Guilt
Preoccupation
Obsession
Phobia
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hipochondry
Delusion of magic-mystic
Delusion of grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicious
Thought of Echo
Thought of Insertion & withdrawal
Thought of Broadcasting

10. Thought Form
Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated

11. Sensorium and Cognition
Level of education : Graduated degree
General knowledge : cant be accessed
Orientation of time : cant be accessed
Orientations of place : cant be accessed
Orientations of people : cant be accessed
Orientations of situation : cant be accessed
Working/short/long memory : cant be accessed
Writing and reading skills : cant be accessed
Visuospatial : cant be accessed
Abstract thinking : cant be accessed
Ability to self care : poor

12. Impulsivity : Self content throught examination : Good
Patient responses towards injuries : Good

13. Insight : Impaired insight
Intellectual Insight
True Insight
14. Physical examination
Status Internus
General Observation : Look mildly sick
Vital sign :
Blood pressure : 120/80 mmHg
Pulse rate : 80 x/mnt
Temperature : Afebrile
RR : 20 x/mnt
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2.


Neurological exam :
Consciousness : Qualitative : Compos Mentis
Quantitative : GCS E4V5 M6
Meningeal Sign : Stiff neck : -
Brudzinsky I : -
Brudzinsky II : -
Laseg : -
Kernig : -
Physiologic Reflex : Biceps : +/++
Triceps : +/++
Patella : +/+
Achilles : +/+
Pathologic Reflex : Hoffman-Trommer : -/+
Babinsky : -/+
Chaddock : -/-
Gordon : -/-
Schaeffer : -/-
Motoric: : 4 4 4 4 1 1 1 1
4 4 4 4 1 1 1 1

Sensoric : Cant be assessed
Nervus cranial : Parese N.VII and N.XII
Cortical function : Repetition : -
Attention : Cant be assessed
Memory : Cant be assessed
Otonom function Miction : Incontinentia urine (-)
Defecation : Incontinentia alvi (-)
Coordination, gait balance : Cant be assessed

V. Summary of Significant Findings
A female patient age 66 years old, former government officer, Javanese ethnic
background, married, was brought to the emergency room of RSJ Magelang on 14 May 2014
because patient was confused and had communication problem. 3 weeks ago patient was
dropped in a bathroom and then cant move her left extremities. The patient had confuse and
communication problems and also talking to herself, cant sleep well and easily to be angry.
Patient cant take care of herself in activity of daily living. Patient dressed as female, poor
groomed, hypoactive, non-cooperative, difficulty in attained attention, unable to sustain
concentration, affect flat, remming, irrelevant answer, intellectual insight.
Symptoms Find
Hemiplegi
Irrelevant Answer
Easily Irritable
Sleep Disturbance
Impairment
Role of Function : poor
Social Function : poor
Grooming : poor
Spartime management : poor
Syndromes Finding
Stroke Syndrome
Hemplegi
Afasia
VII. Differential Diagnosis
F01.0 Acute Onset Vascular Dementia
F06.3 Organic Affective Disorder




VIII. Multiaxial Diagnosis Formulation
Axis I : F06.3 Organic Affective Disorder
Axis II : Z03.2 No Diagnosis
Axis III : Hemorrhagic Stroke
Axis IV : GAF 30 21
X. Problems related to the patient
Organobiologic
- There are abnormality of cerebral perfusion. In stroke, the blood cant perfuse
normally to the brain and disturb the system in the brain, so the patient cant move
her left extremities.

Psychology
- The patient feel disturbed and weak by her condition
Sociology
- The patient cant do her activity daily living normally by herself
- The patient cant communicate with people around her
- The patient live in home by herself

IX. Management Plan
A. Response
Target therapy : Suppress and stabilizes the symptoms (<50%)
Hoapitalized Because the patient cant do activity daily living, being confused and
had communication problem
Pharmacotherapy IVFD Asering 20 drips/second
The patient in infused with Asering for electrolyte balance due
to her nutrient is not in a good condition. The fluid also help in
reduce the bad condition in stroke and give vasodilator effect.
Inj. Piracetam 3 mg
I give piracetam to this patient because first to lowering
depression to this patient due to her condition after stroke.
Second piracetam can improve cognition after stroke and
reduce symptoms such as aphasia. It is used as a
neuroprotector.

Inj. Omeprazole 40 mg
I give omeprazole because to avoid the irritation on the lining
of stomach due the lack of eat by this patient

Olanzapine 1 x 10 mg
I give olanzapine to this patient to treat the psychotic symptom
and positive symptoms of this patient.

B. Remission : Target Therapy : - Improvement in function and cognition
-Medication continue to improve her function and
cognition
-Psychotherapy : Give support and avoid pesimistic.
Conseling the patient in self-beliveness and positive-
thinking.

C. Recovery : Target Therapy : Vocational and social autonomy

Pharmacotherapy
Fluid Therapy : Asering 20 drips/second
Neuroprotector : Piracetam 3 mg
Protein Pump Inhibitor : Omeprazole 40 mg
Antipsychotic : Olanzapine 1 x 10 mg

Psychotherapy
Individual Psychotherapy
- Provide the patient to perform a cooperative in therapy
- Give the motivation, support and counseling so the patient has a spirit and
believeness to be cured.
Family psychotherapy
- Give motivation and education to the family about the patients condition so that
the patient feel comfort

Mr. B, from the examination we conclude that Mrs. W has an organic disorder
that effect her mental status. Organic disorder that effect mental status is an illness
that involves the body, mind and thought. It inteferes with daily life, normal
functioning and causes pain for both the person with the disorder and this
disorder can be happened to anybody but there is a precipitation factor or risk
factor in your daughter or your family. The factor not only came from family but
also from social pressure in the age. You dont have to be worried because a
depressive disorder can be treated and im going to give medication to treat Mrs.
W condition so that she can do her activities such as normal people. The patient
must take this medication regularly because the medication has an advantage to
balance the activity at neurotransmitter. However not only medication that can
affect the healing process so that Mr. B and family must give support to Mrs. W
take the medication regularly and do not treated Mrs. W as a patient, it would be
better if the family treat her like a normal people. Dont force Mrs. W to
understand her family but her family must understand her.


Prognosis
Factors Good Poor
Premorbid
- Family history and
psychiatric
disorder
/
- Marital status /
- Family support /
- Social recognition
status
/
- Stressor /
- comorbid
personality
/
Morbid
- onset > 50 years
old
/
- type of illness :
organic disorder
/
- regression : acute /
- Therapautic
response
/

Conclusion
Ad Vitam : Ad bonam
Ad Sanationam : Dubia ad malam
Ad functionam : Ad malam



Autoanamnese Transcription (14 May 2014)
C : Selamat pagi ibu, saya dokter muda Haikal
P : (pasien melihat ke arah koas)
C : nama ibu siapa ya?
P : W
C : saya mahu ngobrol-ngobral sama ibu ya
P : (Pasien memandang ke arah koas)
C : Ibu sekarang berada di mana? (menanyakan orientasi tempat)
P : (Pasien menjawab dengan jawaban yang tidak bisa di mengerti)
C : Kalau bisa saya tahu anak ibu ada berapa ya? (menanyakan orientasi orang)
P : Empat
C : Cucu ibu ada berapa
P : Sepuluh
C : Ibu ke sini dihantar sama siapa?
P : (pasien diam)
C: Ibu, apa yang dirasakan ibu sekarang?
P : (Pasien berkata dengan kata- kata yang tidak bisa dimengerti)
C : Ibu keluhannya apa?
P : (Pasien diam)

*
Kebanyakan pertanyaan tidak bisa dijawab oleh pasien dan sulit dinilai






Follow Up
16 May 2014
Departemen Jiwa
S O A P
- Jawaban
Irrelevan
- Autisme
- Bingung
F06.3 - Olanzapine
1 x 10 mg
Departemen Saraf
- Bicara
kacau
- Tidak
bisa
tidur 1
minggu
yang
lalu
- Post
stroke 2
minggu
yang
lalu
- Infark
luas
tersangk
a di
carotis
interna
dextra
- KU :
Lemah,
CM, E4 V1
M6, bicara
tidak
nyambung
- Pupil
diameter
2/2 mm,
RC L+/+
RCTL +/+
- N.
Cranialis :
Kesan
Parese
N.VII, XII
- Kekuatan
5 1
5 1

- RF + ++
+ ++

- RP - -
- +

- Refleks
Primitif :
Glabella +
Palmoment
al +

- Post
SNH
- Susp.
Demens
ia
Vaskule
r
- O
2
2 -3 lpm
- IVFD
Asering 16
tpm
- Piracetam 3
g / 6 jam
- Citicholin
500 mg / 12
jam
- Ranitidin 1
amp/ 12 jam
- Displf 2 x 1
mg
- Aspilet 1 x
80 mg
- Arricept 2 x
5 mg
(donepezil)
- Asam folat 2
x 1 mg


- Cek profil
lipid

- EKG dengan
lead II
panjang




18 May 2014
Departemen Jiwa
S O A P
Mulai kooperatif F01.1
F06.1
- Olanzapine 1 x 10
mg
- Lain-lain sesuai
th/ neurologi
Departemen Saraf
- Kekuatan
5 1
5 1
- EKG : Atrial
Fibrillation
- Post- SNH
- AF
- Susp.
Demensia
Vaskuler
- Terapi lanjut
- Konsul Penyakit
Dalam untuk AF
- Fisioterapi

20 May 2014
Departemen Saraf
S O A P
- Bicara (+)
- Kelemahan
anggota
gerak kiri


- KU sakit
sedang,
CM
- Kekuatan
5 1
5 1

- Post-
SNH
- AF
Susp.
Demen
sia
Vaskul
er
- Fisioterapi
- Konsul
Penyakit
Dalam
untuk AF














21 May 2014
Departemen Jiwa
S O A P



- Status
mental
stabil

F06.1 - Olanzapine 1 x
10 mg
Departemen Saraf
Tidur
seharian
- KU lemah
- Pupil
diameter
1,5/1,5 mm,
RC L+/+
RCTL +/+

- Post- SNH
- AF

- Konsul PD untuk
AF
- Fisioterapi
- HCTS ulang




22 May 2014
Departemen Saraf
S O A P
Kesadara
n


- KU lemah,
E4 V5 M6
- Bicara
inkoheren

- Post- SNH
- AF
- Demensia
vaskuler

- Piracetam 2 x
1200 mg
- Ranitidin 2 x 1
- Disolf 2 x 1 mg
- Aspilet 1 x 80
mg
- Asam folat 1 x
5 mg

- Fisioterapi








23 May 2014
Departemen Saraf
S O A P
Penurunan
kesadaran


- KU : Lemah,
CM, E2 V2
M3
- Pupil
diameter
1,5/1,5 mm,
RC L+/+
RCTL +/+
- Tipe nafas
Cheyne
Stoke
- Kekuatan
5 1
5 1

- RF + ++
+ ++

- RP - -
- -

- HCTS : ICH
Lobus
Temporal
dan Parietal
Dextra
- Post- SNH
- AF
- Demensia
vaskuler

- IVFD Asering
24 tpm 200
cc
- Piracetam 1 g/
6 jam
- Manitol 200
cc 6jam
125 cc/ 6 jam
- Ranitidin 1
amp / 12 jam

- Terapi Oral
stop !!

- Konsul ICU
jika bisa

- Head CT Scan

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