SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

MORNING REPORTSaturday, May 17th 2014

Patient IdentityAutoanamnesis• Name : Mr. B• Sex : Male• Age : 24 years old• Address : Purworedjo• Occupation : Unemployed• Marital State : Single

Alloanamnesis• Name : Mrs. S• Sex :Female• Age : 54 years old• Relation : Mother

Reason patient was brought to emergency room

Patient was talking to himself, angry without any reason, unable to sleep

Stressor

Unclear

Day of Admission17th May 2014

Patient brought with the complaints of:

• talking to himself• angry without any

reason• unable to sleep

Brought to hospital by his

mother

He didn’t workPoor utilization of leisure time

He couldn’t socialize with friends

The patient didn’t take any medicine

Past HistoryJune 2013

Patient brought to RSJS by his family because he was mad without any reason. He also disturbed his neighbour. He was hospitalized.

He didn’t go to workHe can’t utilize his leisure timeHe didn’t socialize with neighbor

Patient was given risperidone and clozapine and got bettter after care.

Patient discontinued medication after being discharged from hospital

because he lives far from hospital (not acessible)

PSYCHIATRIC HISTORY

Hospitalized in RSJS for 20 days in June 2013

General

medical

history

•Head injury (-)•Hypertension (-)•Convulsion (-)•Asthma (-)•Allergy (-)

Drugs and

alcohol abuse

history and

smoking

history

•Drugs consumption (-) •Alcohol consumption (-)•Cigarette Smoking (+)

Erikson’s stages of psychosocial development

Stage 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

FAMILY HISTORY

• Patient is the 3rd child of 5 siblings

• Psychiatry history in the family (-)

GENOGRAM

MALE FEMALE Patient

PSYCHOSEXUAL HISTORY

Patient realizes that he is a male, and interests to a female. His attitude is

appropriate as a male.

Socio-economic history

• Economic scale : low

Validity

• Alloanamnesis: valid• Autoanamnesis: valid

Progression of Disorder

Symptom

Role Function

June 2013

May 2014

Appearance

• A male, appropriate to his age, completely clothed

State of Consciousness

• Clear

Speech

• Quantity : Decreased• Quality : Decreased

Mental State 7th May 2014

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

ATTITUDE

• Non-cooperative• Indiferrent• Apathy• Tension• Dependent• Passive

• Infantile• Distrust• Labile• Rigid• Passive negativism• Stereotypy• Catalepsy• Cerea flexibility• Excited

Emotion

Mood• Dysphoric• Euthymic• Elevated• Euphoria• Expansive• Irritable• Agitation• Can’t be assesed

Affect

• Inappropriate• Restrictive• Blunted• Flat• Labile

Disturbance of Perception

Hallucination

• Auditory (-) • Visual (-)• Olfactory (-)• Gustatory (-)• Tactile (-)• Somatic (-)

Illusion

• Auditory (-)• Visual (-)• Olfactory (-)• Gustatory (-)• Tactile (-)• Somatic (-)

Depersonalization (-) Derealization (-)

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

Content of Thought

• Idea of Reference

• Idea of Guilt

• Preoccupation

• Obsession

• Phobia

• Delusion of Persecution

• Delusion of Reference

• Delusion of Envious

• Delusion of Hypochondriac

• Delusion of magic-mystic

• Delusion of grandiose

• Delusion of Control

• Delusion of Influence

• Delusion of Passivity

• Delusion of Perception

• Delusion of Suspicion

• Thought of Echo

• Thought of Insertion &

withdrawal

• Thought of Broadcasting

Form of Thought

• Realistic• Non Realistic• Dereistic• Autism• Cannot be evaluated

Sensorium and Cognition

Level of education : finished junior high school

General knowledge : can’t be accessed Orientation of time : bad Orientations of place : bad Orientations of people : bad Orientations of situation : bad Working/short/long memory: can’t be accessed Writing and reading skills : can’t be accessed Visuospatial : can’t be accessed Abstract thinking : can’t be accessed Ability to self care : can’t be accessed

Self control: enoughPatient response to examiners question:

bad

Impaired insightIntellectual Insight

True Insight

Impulse control when examined

Insight

Physical State

Consciousnes : compos mentisVital sign :

◦Blood pressure : 130/80 mmHg◦Pulse rate : 73 x/mnt◦Temperature : afebrile◦Respiration rate : 22 x/mnt

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 <2”, motoric strength

Neurological exam : not examined

RESUMEDay of admission

Mental Status Impairment

- Hypoactive- Attitude: Tension, labile- Mood: Euthymic- Affect: Restrictive- Perception: none- Thought Progression: Blocking,

poverty of speech- Form of Thought: Realistic- Patient’s response to question:

bad- Intelectual insight

• Got angry easily

• Cutting neighbor’s trees

• Wandering around home holding an axe

• He didn’t work• Poor utilization of

leisure time• He couldn’t

socialize with neighbor

Symptoms

Patient is a male, 53 years old, poor grooming, has a history of adminition in psychiatric ward. Symptoms elevation started since half month ago.

Differential Diagnosis

F20.3 Undifferentiated SchizophreniaF20.5 Residual Schizophrenia

Multiaxial Diagnosis

Axis I : F20.3 Undifferentiated Schizophrenia Z91.1 Noncompliance of medication

Axis II : Z03.2 noneAxis III : noneAxis IV : Social problem (disturbing neighbor)Axis V : GAF admission 20-11

PLANNING MANAGEMENT

Inpatient (hospitalization)To reduce 50% the symptoms : • Got angry easily• Wandering around home holding an axe• Cutting down neighbor’s trees without

any reason

Response Remission Recovery

RESPONSE PHASETarget therapy : 50% decrease of symptoms

Emergency departmentHaloperidol inj 5 mgDiazepam tab 5 mg

MaintenanceHaloperidol 2x5mg

Re-assess patient

REMISSION PHASETarget therapy : 100% remission of symptom

Inpatient management› Continue the pharmacotherapy: maintenance Haloperidol

2x5mg› 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 spend his spare time)

Outpatient management1. Pharmacotherapy2. Psychosocial therapy

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1 year.

- Continue medication, control to psychiatric- Rehabilitation : help patient to find a hobby,

help patient to interact normally with his family and neighbor

- Family education

Thank You…