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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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