MORNING REPORT

Monday 2nd March 2015

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
Patient Identity

Name : Ms. S
Sex : female
Age : 27th years old
Address : Kebumen
Occupation : Unemployed
Marital State : Single
RELATIVES IDENTITY
Name : Mr. K
Sex : Male
Age : 57th years old
Relation : Father
 Reason patient was brought to
emergency room

Patient was brought by her guardian

because she didnt want to eat and didnt
take her medicine for 2 days
Stressor

Unclear
Unclear
Present History
After came back from Jakarta,
patients behavior was
changed.
She begin talked and laughed
by her self,
Isolate her self.
Then she was rampaged.

2005
(1o years a go)
- She didnt want to work
- -She cant utilize her
leisure time
- -She didnt socialize with
neighbor
2006 2007
- The symptoms gets better, patients take - The symptoms gets better, patients take the
the medication regularly medication regularly

- She can work

- She can work
- She can utilize her leisure time
- She can utilize her leisure time
- She can socialize well with her
- She can socialize well with her neighbor
neighbor
2008 2009
- She was rampage
- The symptoms gets better, patients take the
- She get angry easily
medication regularly
- She isolated her self

- She didnt work

- She can work
- She cant utilize her leisure time
- She can utilize her leisure time
- She didnt socialize with her
- She can socialize well with her neighbor
neighbor

She got hospitalized for the 2nd time

2010
- The symptomps repeat and became worsed
because she didnt take her medicine
2011
regularly
- The symptoms gets better,
patients take the medication
regularly
- She didnt work
- She cant utilize her leisure time
- She didnt socialize with her neighbor - She can work
- She can utilize her leisure time
- She can socialize well with her
neighbor
She got hospitalized for the 3rd time
2012 2013
The symptomps repeat and became - The symptomps repeat and became worsed
worsed because she didnt take her medicine
She didnt take her medicine regularly regularly

- She didnt work

- She didnt work
- She cant utilize her leisure time
- She cant utilize her leisure time
- She didnt socialize with her
- She didnt socialize with her neighbor
neighbor

She got hospitalized for the 4th time She got hospitalized for the 5th time
2014
- The symptoms gets better, patients take the
medication regularly

- She can work

- She can utilize her leisure time
- She can socialize well with her neighbor
 Day of Admission
28th February 2015

Patient brought with the

complaints of:
Brought to
hospital by her
she didnt want to eat
father.
and didnt take her
medicine for 2 days

- She also got angry, talked and

laughed by her self without any
reason. Poor utilization of leisure time
She didnt socialize well.
PSYCHIATRIC HISTORY

No history
 Head injury (-)
Hypertension (-)
Convulsion (-)
General Asthma (-)
medical history Allergy (-)

Drugs consumption (-)

Alcohol consumption (-)
Drugs and alcohol
abuse history and Cigarette Smoking (-)
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 bubbling. (6-9 months)

Emotion (NO VALID DATA)

- 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.

Cognitive (NO VALID DATA)

- 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.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor
No valid data on when patient first time climbing the tree or play
hide and seek games, and if patient ever involved in any kind of
sports.
Psychosocial
There were no valid data on patients gender identification,
interaction with his surrounding. There were no data on when
patient first entered primary school, how well patient handle
separation from parents, how well he plays with new friends on
first day of school
Communication
There were no valid data regarding patients ability to make
friends in school, and how many friends patient have during her
schooling period.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Emotion
No valid data on patient adaptation under stress
Cognitive
No valid data on patients grades in school
 LATE CHILDHOOD & TEENAGE PHASE
Late childhood and teenage phase (11-18 years old)
Psychomotor
No data if patient had any favorite hobbies or games, if patient involved in any
kind of sports.
Psychosocial
patient ever had any relationship with opposite gender.
Communication
No valid data on how well the relationship between patient with parents and other
family.
Emotion
No data if patient ever told friend or family regarding any problems. No data if
patient attempted to break the rules (truant school subject, fight with friends,
bullying, ect) and consuming alcohol, smoke and drugs
Cognitive

After graduating from elementary school, patient did not go to school anymore
ADULTHOOD
Educational History
she finished junior high
school
Occupational history
Before she got sick for the
first time, She was a work
on pempek outlet in
Jakarta but she quit.
Marital Status
She wasnt married yet
Criminal History
No
Social Activity
Before she was sick, he was
a friendly girl and had
many friends
Current Situation
She lives with her parents.
 Eriksons stages of psychosocial
development
Stage Basic Conflict Important Events
Infancy Trust vs mistrust Feeding
(birth to 18 months)
Early childhood Autonomy vs shame and doubt Toilet training
(2-3 years)
Preschool Initiative vs guilt Exploration
(3-5 years)
School age Industry vs inferiority School
(6-11 years)
Adolescence Identity vs role confusion Social relationships
(12-18 years)

Young Adulthood Intimacy vs isolation Relationship

(19-40 years)
Middle adulthood Generativity vs stagnation Work and parenthood
(40-65 years)
Maturity Ego integrity vs despair Reflection on life
(65- death)
 FAMILY HISTORY

Patient is the 2nd child of 2 siblings

Psychiatry history in the family (-)

 Genogram

MALE FEMALE Patient Live together

 PSYCHOSEXUAL HISTORY

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

attitude is appropriate as a female.
Socio-economic history

Economic scale : low

Validity

Alloanamnesis: valid
Autoanamnesis: valid
Progression of Disorder
3 months
a go
Symptom

February
2005 2006 - 2013 2015

Role Function
 Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 120/80 mmHg
Pulse rate : 88 x/min
Temperature : Afebrile
RR : 18 x/min
 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
 Mental State
28th February 2015

Appearance
A female, appropriate to her age, completely
clothed
State of Consciousness
Clear

Speech
Quantity : increased
Quality : increased
 BEHAVIOUR

Hypoactive Command automatism

Hyperactive Mutism
Echopraxia Acathysia
Catatonia Tic
Active negativism Somnabulism
Cataplexy Psychomotor agitation
Streotypy Compulsive
Mannerism Ataxia
Automatism Mimicry
Bizarre Aggresive
Impulsive
Abulia
 ATTITUDE

Non-cooperative Infantile
Indiferrent Distrust
Labile
Apathy
Rigid
Tension
Passive negativism
Dependent Stereotypy
Passive Catalepsy
Cerea flexibility
Excited
 Emotion

Mood Affect
Dysphoric Inappropriate
Euthymic Restrictive
Elevated Blunted
Euphoria Flat
Expansive Labile
Irritable
Agitation
Cant be assesed
 Disturbance of Perception

Hallucination Illusion

Auditory (+) Auditory (-)

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

Depersonalization (-) Derealization (-)

 Thought Progression

Quantity Quality

Irrelevant answer
Incoherence
Logorrhea Flight of idea
Blocking Poverty of speech
Confabulation
Remming Loosening of association
Mutism Neologisme
Circumtansiality
Talk active Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
 Content of Thought
Idea of Reference Delusion of grandiose

Idea of Guilt Delusion of Control

Preoccupation Delusion of Influence

Obsession Delusion of Passivity

Phobia Delusion of Perception

Delusion of Persecution Delusion of Suspicious

Delusion of Reference Thought of Echo

Delusion of Envious Thought of Insertion &

Delusion of Hipochondry withdrawal

Delusion of magic-mystic Thought of Broadcasting

 Form of Thought

Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated
 Sensorium and Cognition

Level of education : junior high school

General knowledge : good
Orientation of time : good
Orientations of place : good
Orientations of people : good
Orientations of situation : good
Working/short/long memory : good
Writing and reading skills : good
Visuospatial : not assessed
Abstract thinking : not assessed
Ability to self care : good
Impulse control when Insight
examined

Self control: enough Impaired insight

Patient response to Intellectual Insight
examiners question: True Insight
enough
Symptoms Mental Status
Impairment
Behavior : Hyperactive
Mood : Euforia
Affect : restrictive
Didnt want to Progression of Thought:
eat and take logorrhea, flight of ideas
her medicine Hallucination : She didnt work
Auditory (+) command
Talk ed and Poor utilization
(often heard her younger
laughed by brother ask for help, but according to of leisure time
her self her parents she didnt have younger brother She cant
Got angry because her mother had an abortion)
socialize with
without any Content of thought : thought
others
reason insertion, delusion of control,
delusion of grandious,
Form of thought : non realistic
Insight: Impaired insight
 Syndrome
Delusion : grandious
Schizophrenia
Delusion of control syndrome
Thought insertion

Command auditory hallucination

Thought of insertion Paranoid syndrome
Delusion of control

Euforia
Logorrhea
Flight of ideas Manic Syndrome
Delusion of grandious
 Differential Diagnosis

F20.0 Paranoid Schizophrenia

F25.0 Schizoaffective disorder manic type
F30.2 Manic with psychotic symptom
F31.2 Bipolar disorder, current manic episodes
with psychotic features
 Multiaxial Diagnosis

Axis I : F20.0 Paranoid Schizophrenia

Axis II : R 46.8 Delayed diagnosed of axis II
Axis III : no diagnose
Axis IV : stressor unclear
Axis V : GAF admission 30-21
Problem related to the patient

Problem about patients biological state

Positive symptoms because of an increase in dopamine amount in the post
synaptic neuron
Psychological problems
Even her family support her, but they didnt care much about her medicine.
So the patient have history of not taking her medicine regularly.
Social problem
She cant socialize well with others
PLANNING MANAGEMENT

Response Remission Recovery

Management Planning
Hospitalization
Patient was hospitalized because
Didnt want to eat and take her medicine for 2 days
She was talked and laughed by her self
She get angry without any reason

Emergency Department
Inj. Haloperidol 5 mg 1 Amp IM
Inj. Diazepam 5 mg 1 Amp IV
RESPONSE PHASE
Target therapy : 50% decrease of symptoms

Maintenance Therapy
Haloperidol tab 5mg 2x1

Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom

Inpatient management
1. Continue the pharmacotherapy: maintenance
Inj Haloperidol 50mg/cc IM / 4weeks.
1. Improving the patient quality of life :
Teach patient about her social & environment
(interact with her parents, socialize with her neighbor, get a
new job, find a hobby to do her spare time)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
RECOVERY PHASE
-Continue the medication,
control to psychiatric

-Rehabilitation :
- help patient to find a hobby, help patient
to interact normally with her family and
neighbor
- Family education
 THANK

YOU