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SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT

Saturday 24thMay 2014

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Patient Identity

Autoanamnesis Name : Ms. S

Sex : Female

Age : 27 years old

Address : Purworedjo

Occupation : No job

Marital State : Single

Alloanamnesis Name : Ms. L

Sex : Female

Age : 51 years old

Relation : Mother

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Reason patient was brought to emergency

room

Patient was mad without reason till trying

for kill, talking to herself, unable to sleep

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Stressor

Unclear

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Present History

She couldnt utilize herleisure time

She wont eat

She didnt socialize with

neighbor

May 2014

She mad without any

reason, irritable and

slamming things

She couldnt utilize herleisure time

She didnt socialize with

her neighbor

April 2014

Patient start to have asymptom like was

talking to herself, angry

without any reason till

trying for kill, unable to

sleep

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Day of Admission24thMay 2014

Patient brought with the

complaints of:

Angry without any reason

Talking to herself

Unable to sleep

Slamming things

Brought to

hospital by her

Mother

She cant doing her daily activity,

Poor utilization of leisure time

he couldnt socialize with friends

The patient didnt take

any medicine

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PSYCHIATRIC HISTORY

She was hospitalized in RSJS Magelang

in 2001 and 2007

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Generalmedical history

Head injury (-)

Hypertension (-)

Convulsion (-)Asthma (-)

Allergy (-)

Drugs and alcohol

abuse history andsmoking history

Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (-)

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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric (NORMAL)

- Patients growth and development such as: first time lifting the head (3 months)

rolling over (5 months)

Sitting (8 months)

Crawling (8 months)

Standing (9 months) walking-running (12 months)

holding objects in her hand(5 months)

putting everything in her mouth(3 months)

Psychosocial (NORMAL)- Patient :

started smiling when seeing another face (3 months)

startled by noises(4 months)

when the patient first laugh or squirm when asked to play, nor

playing claps with others (7 months)

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Communication (NORMAL)

- Patient started bubbling. (8 months)

Emotion (NORMAL)

- Patients reaction when playing, frightened by strangers (3 month),

when starting to show jealousy or competitiveness towards other and

toilet training (2 years).

Cognitive (NORMAL)

- The patient can follow objects, recognizing his mother, recognize his

family members. (1-2 years)

- The patient first copied sounds that were heard, or understanding

simple orders. (1-2 years)

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INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (NORMAL)

Patientsfirst time playing hide and seek or if patient ever involved inany kind of sports. (4-5 years)

Psychosocial (NORMAL)

Patient had a normal psychosocial.

Communication (NORMAL) Patient had ability to make friends at school.

Emotional (NORMAL)

Patient had a good emotional.

Cognitive (NORMAL)

Patientscognitive same with others.

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LATE CHILDHOOD & TEENAGE

PHASESexual development signs & activity (NORMAL)

Patient first experience of menarche, etc. (11 Years)

Psychomotor (NORMAL)

Patient had any favourite hobbies or games, if patient involved in any kind of

sports.

Psychosocial (NORMAL)

Patient psychosocial.

Emotional (BAD)

Patient had bad emotional.

Communication (NORMAL)

Patient had ability to make friends at school.

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ADULTHOOD

Educational HistoryShe didnt finish senior high

school.

Occupational historyShe had no job.

Marital Status

She hasnt married

Criminal History

No criminal history

Social Activity

She was a happiness girl.

She joined organization.

Current Situation

She lives with her mother.

She always angry if got

separated with her mother.

Her mother hadnt job and

had financial problem.

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Eriksons stages of psychosocial

developmentStage Basic Conflict Important Events

Infancy

(birth to 18 months)

Trust vs mistrust Feeding

Early childhood

(2-3 years)

Autonomy vs shame and doubt Toilet training

Preschool(3-5 years)

Initiative vs guilt Exploration

School age

(6-11 years)

Industry vs inferiority School

Adolescence

(12-18 years)

Identity vs role confusion Social relationships

Young Adulthood

(19-40 years)

Intimacy vs isolation Relationship

Middle adulthood

(40-65 years)

Generativity vs stagnation Work and parenthood

Maturity

65- death

Ego integrity vs despair Reflection on life

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PSYCHOSEXUAL HISTORY

Patient realizes that she is a female, and interests to a male.

Her attitude is appropriate as a female.

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Socio-economic history

Economic scale: Low

Validity

Alloanamnesis: valid

Autoanamnesis: valid

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FAMILY HISTORY

Patient is the only child.

Psychiatry history in the family (-)

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Genogram

MALE FEMALE PATIENT

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Progression of Disorder

Symptom

Role Function

2001 May 20142007

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Appearance

A female, appropriate to her age, completely

clothed

State of Consciousness

Stupor

Speech

Quantity : Decreased

Quality : Decreased

Mental State

24th

May 2014

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BEHAVIOUR

Hypoactive

Hyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

AutomatismBizarre

Command automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive

Ataxia

MimicryAggresive

Impulsive

Abulia

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ATTITUDE

Non-cooperative

Indiferrent

Apathy

Tension Dependent

Passive

Infantile

Distrust

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcited

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Emotion

Mood

Dysphoric

Euthymic

Elevated

Euphoria

Expansive Irritable

Agitation

Cant be assesed

Affect

Inappropriate

Restrictive Blunted

Flat

Labile

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Disturbance of Perception

Hallucination

Auditory (+) wayangmusic

Visual (+) ghost

Olfactory (-)

Gustatory (-)

Tactile (-) Somatic (-)

Illusion

Auditory (-) Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Depersonalization (-) Derealization (-)

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Thought Progression

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

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Content of Thought

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

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Form of Thought

RealisticNon Realistic

DereisticAutism

Cannot be evaluated

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Sensorium and Cognition

Level of education : didnt go to school

General knowledge : bad

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 : cant be accessed

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Impulse control whenexamined

Self control: bad

Patient response toexaminers question:

bad

Insight

Impaired insight

Intellectual Insight

True Insight

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Physical State

Consciousnes : compos mentis

Vital sign :

Blood pressure : 120/80 mmHg

Pulse rate : 106 x/mnt

Temperature : Afebrile

RR : 20 x/mnt

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Review System

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

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Symptoms Mental Status Impairment

-Behaviour : Active negativism,

Aggresive

-Attitude: Infantile

- Mood: Cant be assesed

- Affect: blunted

- Perception: Auditory, visual

hallucination

- Thought Progression: talk active,

confabulation

- Form of Thought: Non-realistic

- Content of thought: Delusion of

suspicious

- Patients response to question:

bad

- Impaired insight

- Talking to

herself

- Angry

without any

reason

- Unable to

sleep

She cant do herdaily activity,

Poor utilization

of leisure time

He couldnt

socialize with

friends

A woman, appropriate with her age, clothes completely

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Differential Diagnosis

F20.0 Schizophrenia Paranoid

F20.1 Schizophrenia Hebefrenik

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Multiaxial Diagnosis

Axis I : F20.0 Schizophrenia ParanoidZ91.1 Disobeyed of medication

Axis II : Z03.2 No Diagnose

Axis III : No DiagnoseAxis IV : Unclear

Axis V : GAF admission 20-11

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Problem related to the patient

1. Problem about patients life

Patient couldnt manage scedule, she didnt finish her senior

high school because her sick. She always angry if got

separated with her mother. She hadnt father figure. She

refuse to take medicine.

2. Problem about patients biological state

The simplest formulation of the dopamine, serotonin andnorepinephrine hypothesis of schizophrenia posits that

schizophrenia results from too much dopaminergic,

serotonin and norepinephrine activity.

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PLANNING MANAGEMENT

In patient (hospitalization)

To reduce 50% the symptoms :

Talking to himselfAngry without any reason

Unable to sleep

Visual and auditoric hallucinations

Delusion of suspicious

Response Remission Recovery

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RESPONSE PHASE

Target therapy : 50% decrease of symptoms

Emergency department

Haloperidol 5mg i.m

Diazepam 10mg i.v

Maintance

Haloperidol 2x5mg

PlanningECT

Re-assess patient

REMISSION PHASE

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REMISSION PHASE

Target therapy :

100% remission of symptom

Inpatient management

1. Continue the pharmacotherapy: maintenance Haloperidol

2x5mg

2. ECT plan3. Improving the patient quality of life :

Teach patient about his social & environment

(interact with his parents, socialize with his neighbor, get a new

job, find a hobby to do his spare time)

Outpatient management

1. Pharmacotherapy

2. Psychosocial therapy

RECOVERY PHASE

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RECOVERY PHASE

Target therapy : 100% remission of symptom within 1

year.

- Continue the medication, control to psychiatric

-Rehabilitation : help patient to find a hobby, helppatient to interact normally with her family and

neighbor

- Family education :

- explain to the family about the mental disorder and

the treatment.

- Educate the family to support not to exile the

patient.

- Ask the family to monitor patient progress and makesure the patient take medicine as prescribe.

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