MORNING REPORT

Wednesday, 30th October 2013

A. PATIENTSS IDENTITY
Name : Mrs. S
Age : 26 years old
Gender : Female
Address : seneng 03/01 banyurojo mertoyudan magelang
Occupation : Unemployed
Marriage status : Single
Last education : Senior high school
GUARDIANS IDENTITY
Name : Mr. S
Age : 72 years old
Relation : Father
B. CAUSES BROUGHT THE PATIENT TO THE HOSPITAL
Patient believe that she will be die and unable to communicate well with
others.
C. PRESENTING ILLNESS
A woman taken to hospital by her father. According to her father, since 4
days ago his daughter starting to talk and laugh alone. Beside that her father
said that his daughter suddenly faint twice when they walk. The patient
difficult to sleep, felt that everybody hate her, everybody talk about her, felt
difficult to breath and will be death. Her father also said that his daughter
easily becomes angry. The patient said that she heard the voices of God and
prophet that told her she will be die. Her father said that in august 2013 his
daughter was taken to RSJ Soerojo because of the same reason and she got
discharge from hospital in September 2013.
D. HISTORY OF PRESENT ILLNESS
Psychiatry history
2005 = The patient diagnosed suffer from schizophrenia
2010 = The patient diagnosed suffer from schizophrenia
2012 = The patient diagnosed suffer from schizoaffective
General medical history
None
Drugs and alcohol abuse history and smoking history
Alcohol consumption (-)
Tobacco consumption (-)
drug use (-)
E. PERSONAL HISTORY
1. Early Childhood Phase (0-3 Years Old)
Psychomotoric (NO VALI D 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 VALI D 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 VALI D DATA)
There were no valid data on when patient started saying words 1
year like bapak or ibu. (6-9 months)


Emotion (NO VALI D 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 VALI D DATA)
There were no valid data on which age the patient can follow
objects, recognizing her mother, recognize her family members.
There were no valid data on when the patient first copied sounds
that were heard, or understanding simple orders.
2. Intermediate Childhood (3-11 Years Old)
Psychomotor (NO VALI D DATA)
No valid data on when patients first time climbing the tree or hide
and seek, if patient ever involved in any kind of sports.
Psychosocial (NO VALI D DATA)
There were no valid data on patients gender identification,
interaction with him surroundings
There were no data on when patient first entered primary school,
how well patient handles seperation from parents, how well he
plays with new friends on first day of school
Communication (NO VALI D DATA)
There were no valid data regarding patients ability to make friends
in school, and how many friends patient have during his schooling
period.
Emotional (NO VALI D DATA)
No valid data on patients adaptation under stress
Cognitive (No VALI D DATA)
No valid data on patients grades in school



3. Late Childhood & Teenage Phase
Sexual development signs & activity (NO VALI D DATA)
No data on when patient experience menarche, hair on armpits or ,
etc
Psychomotor (NO VALI D DATA)
No data if patient had any favourite hobbies or games, if patient
involved in any kind of sports.
Psychosocial (NO VALI D DATA)
No data if while growing up did she make many friends, how well
patient make any friends and how much friends.
No valid data on when and how patients relationship with
different gender, if patient ever had any relationship with the
opposite gender.
Emotional (VALI D DATA)
Patient seldom told friends or family regarding any problems.
No data if patient attempted to break the rules (truant schools
subject, fight with friends, bullying, etc) and consuming alcohol,
smoke and drugs
Communication (NO VALI D DATA)
Patient has a good relationship with parents and other family.
4. Adulthood
Educational History
Senior High School
Occupational history
None
Marital Status
unmarried
Criminal History
None
Social Activity
Patient seldom to get
interaction with her neighbour
Current Situation
Lives with his parents
Religious history
Pray routinely before illness


F. Eriksons 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
Conclusion:
She is a quite person and seldom to tell a friend or family about her problems so
she have a social relationships problems.
G. History
Family History
The patient is the last child from 4 siblings and she has two brothers and one
sister. All her siblings already married and she is the only one who havent.
Psychosexual history
Patient psychosexual history is appropriate of her gender. She realize that she is a
female and behaves according to her gender.
Genogram
Socio-economic history
Economic scale : low
Validity
Alloanamnesis : valid
Autoanamnesis : valid
I. PROGRESSION OF ILNESS
J. MENTAL STATUS
Appearance :
A woman, appropriate according to age, wear complete clothes, and good self
grooming.
State of Consciousness: Clear
Speech:
Quantity : increased
Quality : decreased
Behaviour :
Psychomotor agitation
Aggresive
Attitude:
Non-cooperative
Infantile
Labile
Emotion
Mood: Irritable
Afect: Appropriate
Disturbance of perception
The patient said that she heard the voices of GOD and prophet it means she has a
hallucination of auditory.
Thought of progression
Quantity : Talk active
Quality : Loosening of association
Content of thought : Delusion of reference
Thought of progression : Non-realistic
Sensorium and cognition
Level of education : enough
General knowledge : undeferrentiated
Orientation of time/place/people/situation : good
Working/short/long memory : cant be assessed
Writing and reading skills : cant be assessed
Visuospatial : cant be assessed
Abstract thinking : cant be assessed
Ability to self care : decrease
Note: The patients condition is non-cooperative. The patient easily to get angry
when someone asked her. So some data cant be assessed.
Impulse control when examined
Self control : bad
Patient response to examiners question : bad
Insight : Intelectual Insight
K. INTERNAL STATUS
Conciousnes : compos mentis
Vital sign:
Blood pressure : 140/80 mmHg
Pulse rate : 104 x/mnt
Temperature : afebris
RR : 24 x/mnt
Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
- Cor : S1,2 Sound and normal
- Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2
L. NEUROLOGICAL STATUS
Motorik : Normotonus, good coordination of movement
Meningeal sign : negative
Physiologic reflect : +/+
Patologic reflect : -/-
M. SIGNIFICANT FINDING RESUME
Onset: 2 months ago
Stressor: problem with husbands family and financial problem
Symptoms
o Anger tantrums, Agitated and sensitive
o Hearing voices
o Felt everybody hate and talk about her
Disability
o Unemployed
o Social withdrawal
Mental Status
o Behaviour : Agressive, Psychomotor agitation, Cataplexy
o Attitude : Non cooperative
o Mood : Irritable
o Affect : Aproppriate
o Thought progression : lossening of association
o Form of thought : Non-realistic
o Insight : intellectual insight
N. DIFFERENTIAL DIAGNOSE
F20.0 Paranoid schizophrenia
F20.2 Schizoaphrenia catatonic type
F31.0 Bipolar affective disorder, current episode of hypomania
O. MULTIAXIAL DIAGNOSE
Axis I : F 20.0 Paranoid Schizophrenia
Axis II : R 61.0 Mixed personality disorder
Axis III : no diagnose
Axis IV : Social environment problem
Axis V : GAF admission 20-11
GAF 1 year recent 40-31
P. PLANNING MANAGEMENT
1. Hospitalization: Fixation and pharmacotherapy.
a. Purpose of hospitalization is to decrease the aggressive symptoms, so patient
can handle herself, and not threatening people around him.
b. Hospital treatment plans should be oriented toward practical issues of quality
of life, role function and social relationships.
c. To establish an effective association between patients and community support
systems.
d. Pharmacotherapy
Emergency Room : Inj Diazepam mg IV & Inj Haloperidol 5mg IM
Routine therapy : Antipsikotik tipikal & Haloperidol 2 x 5mg
2. Psycho-education after medication
Educate the patient and family after medication:
Explain to patients family about mental disorder. There are many factors cause
the symptoms, such as biommoleculer imbalance in the brain, so we need
various aspects for the treatment.
Dont force the patient to understand the family instead vice versa.
Treat the patient according to the familys ability, dont demand the patient
more nor less.
Help the patient when she needs it.
Education of the family to encourage communication and understanding.


Question:
What should we do or explain if the patients ask about why the drugs should
be consume routinely?
Answer:
The drugs is for curing the sickness, but if the patient already cure by the
medicine the drugs should be consume routinely to make the patient still stable
and not relaps. But the most important the drugs keep the pysche health not
being regression and still health (not frequently relaps).