SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT

Sunday Morning, January 26th 2014

I. PATIENT’S IDENTITY

AutoanamnesisName : Mr. KAge : 56 years oldGender : MaleAddress : KebumenOccupation : Unemployed (ex- Labor)Marital status : MarriedLast education : Engineering schoolAlloanamnesisName : Mr. ZAge : 44 years oldRelation to patient : Younger brother

REASON PATIENT WAS BROUGHT TO HOSPITAL

Broke the household, talk to herself,

wandering around and didn’t come back

STRESSOR

Probably lost her job because of disaster

- Self grooming got worse :• Didn’t want to eat• Didn’t want to sleep• Didn’t want to take a bath- Poor utilization of leisure time- Social withdrawl

Present History 2 weeks ago

4 days ago•Patient looked sorrow, more quiet and oftenly by himself

•The patient told his wife that he heard the voice of many people want to kill him and his family and cut his body

•Patient looked confuse

- Has not worked.- Patient was wandering around, but

still able to come home. Never talk to his neighbors (social withdrawl)

- Poor utilization of leisure time- Self grooming still good

• The symptoms getting worse

• Looking more confuse• Loss of appetite and only

taking bath when he is asked

• Patient gave a knife to his wife to protect herself as he thought that someone

wanted to kill him and his family

Present History 1 day ago•Patient told his family that he wanted to go to his neighbor’s house. But the patient didn’t go home, and found naked in the field. The patient took off his clothes because he thought that he has been followed.

Has not worked., bizzare behaviourPatient was wandering around and not

coming back Poor utilization of leisure timeSelf grooming worser

Present History Day of admission

• The symptoms get worse• When his brother visits him, he threatens his brother with his carpenter tools.

• The family concerned about the patient’s condition

• Patient was accompanied by his brother

Self grooming got worsePoor utilization of leisure time

Social relationship getting worse

Psychiatric History

•Patient has psychiatric history before. 8 years ago the patient being hospitalized in RSJ Magelang for 2 weeks. The patient didn’t take the medicine afterwards and did not go to the hospital for his medical check up.

•Head injury (-)•Hypertension (?) – no valid data•Convulsion (-)•Asthma (-)•Allergy (-)•History of admission (-)

General medical history

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

Drugs and alcohol abuse

history and smoking history

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (NO VALID DATA) • 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)

Psychosocial (NO VALID DATA) • 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)

Communication (NO VALID DATA) • There were no valid data on when patient started saying words 1 year like ‘mom’ or ‘dad’.

(6-9 months)

Emotion (NO VALID DATA) There were no valid data of patient’s reaction when playing,

frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (NO VALID DATA) There were no valid data on which age the patient can follow objects,

recognizing her mother, recognize his family members. There were no valid data on when the patient first copied sounds

that were heard, or understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (NO VALID DATA) No valid data on when patient’s first time playing hide and seek or if patient

ever involved in any kind of sports.

Psychosocial (NO VALID DATA) No valid data on patient interaction with his surrounding, no valid data on

when patient first entered primary school, on how well patient handle separation from parent, how well he play with his new friend on first day school.

Communication (NO VALID DATA) No valid data regarding patient ability to make friends at school and how

many friends patient have during his school period

Emotional (NO VALID DATA)No valid data on patient’s adaptation under stress, any incidents of

bedwetting were not known.

Cognitive (NO VALID DATA)No valid data on patient’s cognitive.

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA) No data on when patient first experience wet dream, etc.

Psychomotor (NO VALID DATA) No data if patient had any favourite hobbies or games, if patient involved in

any kind of sports.Psychosocial (NO VALID DATA)

Patient had never been told the parent about patient friend.Emotional (NO VALID DATA)

No valid data on patients reaction on playing, scared, showed jealously or competitiveness

Communication (NO VALID DATA) No valid data on how well the relationship between patient with parent and

other family.

ADULTHOOD Educational History

Engineering School

Occupational history Unemployed

The patient worked as labor for 10 years, unsettled work place. 2 weeks ago patient got fired because the company was bankrupt

Marital Status Married

Criminal HistoryNo

Social Activity Restricted, only have a few

friends.

Current Situation He lives with his wife and one child

Erikson’s 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

Family history

Patient is the 1st child out of seven siblings.

Patient has 3 children that lives and only one child living together with him and his wife

Psychiatry history in the family (-)

Patient realises that he is male, his behaviour is appropriate for male and is attracted to woman.

Psychosexual history

Genogram• Suffers from

mental illness• Female• Male

Socio-economic history• Economic scale : average

Validity

• Alloanamnesis : valid• Autoanamnesis : not valid

Progression of disorder

Symptom

Role function

2006 2014

Mental State(Sunday Morning, 26th January 2014)

Appearance • a woman, appropriate to her age, completely

clothedState of Consciousness• Clouded

Speech• Quantity : decreased• Quality : decreased

Behaviour

HypoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStreotypyMannerismAutomatismBizarre

Command automatismMutismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia

ATTITUDE

• Non-cooperative

• Indiferrent• Apathy• Tension• Dependent• Passive

• Infantile• Distrust• Labile• Rigid• Passive negativism

• Stereotypy• Catalepsy• Cerea flexibility• Excitement

Emotion

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

Affect• Appropriate• 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 progressionQuantity

• Logorrhea• Blocking• Remming• Mutism• Talk active

Quality• Irrelevant answer• Incoherence• Flight of idea• Poverty of speech• Confabulation• Loosening of association• Neologisme• Circumtansiality• Tangential • Verbigrasi • Perseverasi • Sound association• Word salad• Echolalia

Content of thought

Idea of Reference Idea of GuiltPreoccupationObsessionPhobia Delusion of PersecutionDelusion of ReferenceDelusion of JealousyDelusion of HipochondryDelusion 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

Form of thought

RealisticNon RealisticDereisticAutistic

Sensorium and Cognition Level of education : average General knowledge : average Orientation of time/place/people/situation:

bad/good/good/bad Working/short/long memory: not cooperative Writing and reading skills : not cooperative Visuospatial : not cooperative Abstract thinking : not cooperative Ability to self care : poor

MMSE Orientation of time/place/people/situation:

bad/bad/bad/bad Registration : poor Attention : poor Memory : poor Language : not cooperative Visuospatial : not cooperative

MMSE couldn’t be asseses completedly because the patient is not cooperative

Impulse control when examined•Self control: enough•Patient response to

examiners question: poor

Insight •Impaired insight•Intellectual Insight•True Insight

Internal StatusConsciousnes : compos mentisVital sign :

◦Blood pressure : 120/90 mmHg◦Pulse rate : 100x/mnt◦Temperature : afebris◦RR : 20 x/mnt

Head : normocephali

Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax:

Cor : S 1,2 Sound and normal

Lung : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2”,

Neurological exam : not examined

RESUMEOnset : 2 weeks ago

Symptoms

Patient easily got angry to her husband

Patient often threw the clothes from the

cupboard and didn’t put them back.

Broke the glassTalk to herself

Laugh to herselfCrying without any

reasonWandering around and didn’t came back home

Mental Status

HypoactiveDysphoricAppropriateRemmingDelusion persecution,idea of guilt, idea of reference Auditoric halluscination (+)Form of thought : AutisticWorking/short/long memory: poorRegistration : poorAttention : poorMemory : poorImpaired insight

Disability

Has not worked.Poor utilization of

leisure timeSelf grooming got

worse Social withdrawl

• Patient looked sorrow, more quiet and oftenly by himself

• The patient told his wife that he heard the voice of many people want to kill him and his family and cut his body

• Patient looked confuse• Loss of appetite and only

taking bath when he is asked• Patient and found naked in

the field.• he threatens his brother with

his carpenter tools.

Differential Diagnosis

F20.0 Schizophrenia ParanoidF23.1 Acute Polymorfic Psychotic

Disorder with Schizophrenia Symptom

F25.3 Schizoaffective Disorder Depressive type

Multiaxial DiagnosisAxis I : F 20.0 schizofrenia paranoidAxis II : R46.8 delayed diagnosis of axis IIAxis III : No diagnosisAxis IV : Problem with occupation and economic

status (patient’s got fired from his recent job)

Axis V : GAF admission 20-11

PLANNING MANAGEMENT

Inpatient (hospitalization)The patient had shown aggressive behaviour that was disrupting and endanger people around him.

Response Recovery

RESPONSE PHASE

Emergency department Inj. Haloperidol 5mg i.m. Inj. Diazepam 10 mg i.v.

Ward (routine therapy)Antipsychotics : Tab Haloperidol 5mg

s2dd1 tab

RECOVERY PHASE

Outpatient managementPharmacotherapyOccupation Therapy

Thank You…