Friday , November 21st 2014

MORNING REPORT

Supervisor:
dr. Sabar P Siregar Sp.KJ
 Patient’s Identity
• Name : Mrs. Sulastri
• Age : 55 years old
• Gender : Female
• Address : Timbelan
• Occupation : Labour
• Marriage Status : Married
• Religion : Islam
• Last Education : Elemantry School
 Alloanamnesis
Guardian
• Name : Mr. Hasadi
• Age : 60 years old
• Relation : Husband
 Complaint
• Patient is brought to the hospital by
her husband due to his wife was
angry to other people.

• Patient rampage until break

neighbor’s house mirror.
 Stressor
• She always thinking her daughter
who have mental disorder.
 Progression of illnes
March 2013
(1 years before The patient began to talk, smile and laugh herself.
admission) Patient lazy to work. Patient was angry to other so
that the family admit her to RSJ magelang

November 2014 The patient was angry and rampage to other people
( 10 days before until throwing stone to neighbour’s house mirror,
admission) difficult to get sleep, rarely to take a bath. Patient also
hear crackle water and feel her house was
surrounded by people.

On the day of
admission
The Symptoms are worsen
The family is concerned about the patient’s condition.
 Present Illness
• Psyciatry History
Patient was diagnosed with Schizophrenia Undifferentiated since
2013.
• Medication
Chlorpromazine 100mg 1x1
Trihexyphenidyl 2mg 2x 1
Haloperidol 5mg 2x 1
However patient stopped taking drugs because her husband feels
she is healthy.
• Trauma
No history of recent trauma
• Drugs and alcohol abuse history and smoking history
- Alcohol consumption (-)
- Tobacco consumption (-)
- Drug use (-)
History of Personal Life
1. Prenatal and Perinatal History
2. Early childhood phase
3. Intermediate childhood
4. Late childhood
5. adulthood
Prenatal and Perinatal history

• Her husband did not know about any

medical condition during pre and
perinatal (no valid data).
 Developmental History (Gross Motoric)

Ability Result Normal range

Elevating the head Normal 0-3 months

Moving to supine position Normal 3-6 months

on its own
Sitting Normal 6-9 months

Standing Normal 9-12 months

Walking Normal 12-24 months

Climbing up the ladder Normal 24-36 bulan

Standing 1 foot / jump Normal 36-48 bulan

 Developmental History (Fine Motoric)

Ability Result Normal range

Holding a pencil Normal 3-6 months
Holding 2 objects at the same time Normal 6-9 months

Piling 2 cubes Normal 9-12 months

Inserting objects into container Normal 12-18 months
Rolling a ball Normal 18-24 months
Doodling Normal 24-36 months
Wearing shirt Normal 36-48 months
 Developmental History (Language)

Ability Result Normal range

Oooh-aah Normal 0-3 months

Turning toward the sound Normal 3-5 months

High-pitched sound Normal 3-6 months

Voice without meaning (mamama, Normal 6-9 months

Bababa)
Calling 2-3 syllables without meaning Normal 9-12 months

Calling 3-6 words that have meaning Normal 18-24 months

Talking at least with two words Normal 24-36 months

Mentioning name, age, and place Normal 36-48 months

 Developmental History (Social & Personal)

Ability Result Normal range

Know their mother Normal 0-3 months
Reach out Normal 3-6 months
Clap Normal 6-9 months

Playing peek a boo Normal 6-9 months

Know their family Normal 9-12 months

Appoint what he wants without crying Normal 12-18 months
or whining
Tidy up toys Normal 24-36 months
Playing with friends, follow the rules Normal 36-48 months
of the game
Intermediate Childhood (3-11 years old)
•Psychomotor (NO VALID DATA)
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 (NO VALID DATA)
There were no valid data on patient’s 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
friendson first day of school
•Communication (NO VALID DATA)
There were no valid data regarding patient’s ability to make friends in
school, and how many friends patient have during his schooling period.
•Emotion (NO VALID DATA)
No valid data on patient adaptation under stress
•Cognitive (NO VALID DATA)
No valid data on patient’s grades in school
Late Childhood and Teenage Phase
•Sexual Development Sign and Activity (NO VALID DATA)
No data on when patient experience wet dream, growth hair on armpits,
growth pubic hair, 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)
No valid data on when and how patient’s relationship with different gender,
if patient ever had any relationship with opposite gender.
•Communication (NO VALID DATA)
No valid data on how well the relathionship between patient with
parents and other family.
•Emotion (NO VALID DATA)
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
 Adulthood
• Educational History • Current Situation
Elementary School Live with her husband and
daughter.
• Marriage Status
• Religious History
married
Moslem
• Social Activity
• Criminal History
Normal interaction
No criminal history
• Occupational History
Labour
 Erikson’s 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)

Conclusion: no clear data

 History
Family history
• she is the 6th daughter from 6 siblings
• Her sister and daughter have psychiatry
disorder
Psychosexual History
• Patient psychosexual history is
appropriate to her gender. She realizes
that she is female and behaves according
to her gender.
Genogram
Socio-Economic History
• Economic Scale : Poor

Validity
• Alloanamnesis : Valid Data
• Autoanamnesis : Valid Data
 Symptom

Mar 2013 Nov 2014

Role of Function
 Mental State
(November, 21th 2014)
•Appearance
A Female, appropiate to his age, wear complete
clothes, poor self grooming.
•State of Consciousness
Clear
•Speech
- Quantity : increase
- Quality : Decrease
 BEHAVIOUR
Mannerism
Hypoactive Psychomotor
Automatism agitation
Hyperactive
Bizarre Compulsive
Echopraxia
Command Ataxia
Catatonia
automatism
Active negativism Mimicry
Mutism
Cataplexy Aggresive
Acathysia
Stereotypy Impulsive
Tic
Abulia
Somnabulism
 ATTITUDE
Non-
cooperative Passive
Infantile
negativism
Indiferrent Distrust
Catalepsy
Apathy Labile
Cerea flexibility
Tension Rigid
Excitement
Dependent
 Emotion

Mood Affect
• Appropriate
• Dysphoric • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
• Can’t be assesed
 Disturbance of Perception

Hallucination Illusion
• Auditory (+) hears crackle
water. • Auditory (-)
• Visual (-) • Visual (-)
• Olfactory (-) • Olfactory (-)
• Gustatory (-)
• Gustatory (-)
• Tactile (-)
• Somatic (-) • Tactile (-)
• Undeferrentiated (-) • Somatic (-)
• Undeferrentiated (-)

Derealisation (-)
Depersonalisation (-)
 Thought Progression
Quantity Quality
• Irrelevan answer
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Confabulation
• Mutisme • Poverty of speech
• Slow speech
• Talkative
• Loosening of association
• Neologisme
• Circumtansiality
• Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
 Content of thought
 Idea of Reference  Delusion of Grandiose

 Preocupation  Delusion of Control

 Obsession  Delusion of Influence

 Phobia  Delusion of Passivity

 Delusion of Persecution  Delusion of Perception

 Delusion of Reference  Thought of Echo

 Delusion of Envious  Thought Insertion

 Delusion of Hipochondry  Thought of withdrawal

 Delusion of magic-mystic  Thought Broadcasting

 Fantasy  Can’t be assesed

 Form of Thought

• Realistic

• Non Realistic

• Dereistic

• Autistic
 Sensorium and Cognition
 Level of education : Low
 General knowledge : Low
 Orientation of time/
place/people/situation : Poor/poor/poor/poor
 Working/short/long memory: Poor/good/good
 Writing and reading skills : poor
 Ability to self care : poor
Impulse Control When Examined
• Self control : Average.
• Patient response to examiners
question: Good.

Insight
• Impaired insight (patient do not
know he is mentally ill)
• Intelectual Insight
• True Insight
 Physical examination
 Conciousness : Clear

 Vital sign:
- Blood pressure : 130/80 mmHg
- Pulse rate : 92 x/min
- Temperature : afebris
- RR : 20 x/min
•Skin : rash(-), petechiae (-)
•Head
• Eye : conjunctival pallor (-), yellowish sclera (-)
• Nose : discharge(-), nasal flare (-)
• Ear : discharge(-)
• Mouth : within normal limit
• Neck : lymphnodes within normal limit
• Lungs : symmetrical, retraction(-), vesicular (+/+),
abnormal lung sounds (-/-)
• Heart : S1, S2 regular, murmur(-), cardiomegaly
(-)
• Abdomen : Supple, tympany (+), Distention (-),
Hepatomegaly (-), Splenomeogaly (-)
Neurological Status
• Motorik : Normotonus, good coordination of movement

• Meningeal sign : negative

• Physiologic reflex : +/+

• Patologic reflex : -/-

 Significant Finding Resume

Onset Symptoms : 10 days ago

Mental status Impairment

•Rarely to take a
Mood: Euphoria
The patient was angry
Affect: inappropriate,
bath
and rampage to other
people until throwing Disturbance of •Lazy to work
stone to neighbour’s perception: •Limited social
hallucination of
house mirror, difficult to
auditory(+),
interaction
get sleep, rarely to take a
bath. Tought progression:
- Quality: Loosening of
Patient also hear crackle Association
water and feel her house - Quantity: Loghorrea
was surrounded by Content of tought :
people. Delusion of
Persecution
Form of tought: Non
realistic
 Differential diagnosis
• F20.0 Schizophrenia paranoid
• F25.0 Schizoaffective Manic Type
 Multiaxial Diagnose
Axis I :F25.0 Schizoaffective Manic Type
Z91.1 ketidak patuhan minum obat
Axis II :-
Axis III :-
Axis IV : Family problem ( her daughter )
Axis V : GAF admission 30 – 21 disabilitas berat dalam
komunikasi dan daya nilai tidak mampu
berfungsi hampir semua bidang.
PROBLEM RELATED TO THE
PATIENT
1. Problem about patient’s life (social)
Do not have close friend
Impulsive and inpolite behavior towards family member
Didn’t disobedient of taking drug

2. Problem about patient’s biological state (biology)

There were abnormality imbalance neurotransmitter, hyperactivity of
serotonin and dopamine.

3. Problem about patient’s mental state (psychology)

Feels suspicious toward others
Auditory hallucination
PLANNING MANAGEMENT
PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
• Rampageness
• Auditory hallucination
• Did not take medication as scheduled

Emergency department
Inj. Diazepam 1 ampule IV for sedative
Inj. Haloperidol 1 ampule IM
 RESPONSE PHASE
Target therapy :
50% decrease of symptoms

Maintenance
Haloperidol 2 x 5mg
Triheksiphenidil 2 x 2mg if needed
Lithium carbonat 2 x 200mg
 REMISSION PHASE
 Target therapy :
- 100% remission of symptom

 Inpatient management
- Continue the pharmacotherapy:
Haloperidol 2 x 5mg
Triheksiphenidil 2 x 2mg if needed
Lithium carbonat 2 x 200mg
- Improving the patient quality of life :
Teach patient about her social & environment (interact with her
family, socialize with her neighbor or friends, find a hobby to do on
her spare time)
 Outpatient management
- Pharmacotherapy
 RECOVERY PHASE
Continue the medication, control to psychiatric

Rehabilitation :
- Help patient to interact normally with
her family, friends, and neighbor
- Do some activities that can keep patient
occupied
- Family education
TERIMA KASIH