S U P E R V I S O R D R . S A B A R P. S I R EG A R , S P . K J

MORNING REPORTsaturday, May 31th 2014

Patient Identity

Autoanamnesis Name : Mrs. S Sex : Female Age : 36 years old Address : Banjarnegara Occupation : unemployed Marital State: widowed

Alloanamnesis Name : Mrs. J Sex : Female Relation : Mother’s patient Age : 58 years old

PAT I E N T A N G RY W I T H O U T R EA S O N , S H O U T A N D I R R I TA B I L I T Y.

Reason patient was brought to emergency room

Stressor

Unclear

Present HistoryAbout 2013 years:• Angry without reason

• Shout• talk with her self• Decrease appetite• Poor grooming

Hospitalization in RSJ Magelang (6 march- 21

may)

About 5 days ago:• Often showed anger

• shout• Irritability

• Didn’t to take medication

About 2012 :• Angry without reason

• Shout• talk with her self• Decrease appetite• Poor grooming

Hospitalization in RSJ Magelang (15 May-11July)

2011Her husband is

death

Day of AdmissionMay, 31th 2014

Patient was brought with the complaints of:

• Showing anger• shouting• Irritability

• Don’t want to take medication

Brought to hospital by her mother

Poor utilization of leisure timeCan’t socialize with others anymore

Sleep disturbancesdecrease of appetites

Psychiatric History

Patient has no psychiatric problems history before

• Head injury (-)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)

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 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 his hand(3-6 months) putting everything in his mouth(3-6 months)

Psychosocial 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 There were no valid data on when patient started bubbling. (6-9

months)Emotion

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 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.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor 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 regarding patient psychosocial.Communication

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 on patient’s emotional.

Cognitive 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 of menarche, ect.

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 regarding patient psychosocial.Emotional (NO VALID DATA)

No valid data on patient’s emotional.Communication (NO VALID DATA)

No valid data regarding patient ability to make friends at school and how many friends patient have during his high school period

ADULTHOOD

Educational History she finished elementary school

Occupational History She’s never worked

Marital Status widowed

Criminal History No

Social Activity she was quiet

Current Situation she lives with her parents and

her son

Erikson’s 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

FAMILY HISTORY

Patient is the 1st child of 3 siblings

There is no psychiatry history in the family

Male Female Patient Lives together

GENOGRAM

PSYCHOSEXUAL HISTORY

Patient realizes that she is a female, and interested in man. Her attitude is

appropriate as a female.

Socio-economic history• Economic scale : low

Validity • Alloanamnesis : valid• Autoanamnesis : can’t be access

Symptom

Role Function

May 2012

March2013

Progression of Disorder

May 2014

Mental State - May 31th 2014

Appearance • A female, appropriate to her age, completely clothed,

poor groomed

State of Consciousness• stupor

Speech• Quantity : can’t be access• Quality : can’t be access

BEHAVIOUR

•Hypoactive•Hyperactive•Echopraxia•Catatonia•Active negativism•Cataplexy•Streotypy•Mannerism•Automatism•Bizarre

•Command automatism•Mutism•Acathysia•Tic•Somnabulism•Psychomotor agitation•Compulsive•Ataxia•Mimicry•Aggresive•Impulsive•Abulia

ATTITUDE

• Non-cooperative• Indiferrent• Apathy• Tension• Dependent• Passive

•Infantile•Distrust•Labile•Rigid•Passive negativism•Stereotypy•Catalepsy•Cerea flexibility•Excited

Emotion

Mood

• Dysphoric• Euthymic• Elevated• Euphoria• Expansive• Irritable• Agitation

Affect• 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 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

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

Form of Thought

•Realistic•Non Realistic•Dereistic•Autism•Cannot be evaluated

Sensorium and Cognition

Level of education : finished elementary school General knowledge : Can’t be assessed Orientation of time : Can’t be assessed Orientations of place : Can’t be assessed Orientations of people : Can’t be assessed Orientations of situation : Can’t be assessed Working/short/long memory: Can’t be assessed Writing and reading skills : Can’t be assessed Visuospatial : Can’t be assessed Abstract thinking : Can’t be assessed Ability to self care : Can’t be assessed

Impulse control when examined

• Self control: poor• Patient response to

examiners question:poor

Insight

• Impaired insight• Intellectual Insight• True Insight

Physical State

Consciousnes : clear consciousnessVital sign :◦Blood pressure : 120/70 mmHg◦Pulse rate : 86 x/mnt◦Temperature : 36.5 C◦RR : 20 x/mnt

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 Status Impairment

- Behavior: hiperactive, catatonia, active negativism, mutism-Attitude: non-cooperative, apaty, rigid-Affect: flat-Thought of Progression: remming-Form of thought : autism

• Often forius anger• shout• Irritability• do wan’t to take

medication

Poor utilization of leisure time

Can’t socialize with others anymore

Sleep disturbancesLoss of appetites

Symptoms

Patient is a female,36 years old, poor groomed, has no history of admittion in psychiatric ward.

RESUME - Day of admission

F20.2 schizophrenia catatonicF20.3 schizophrenia undifferentiated

Differential Diagnosis

Axis I : F20.2 Schizophrenia CatatonicZ91.1 Disobeyed of medication

Axis II : Z03.2 No DiagnoseAxis III : -Axis IV : 3 years ago, her husband is died. Her

daughter live with her uncle and aunt.Axis V : GAF admission 20-11

Multiaxial Diagnosis

PROBLEM RELATED TO THE PATIENT

1. Problem about patient’s life3 years ago, her husband is died. Her daughter live with her uncle and aunt.

2. Problem about patient’s biological state There were abnormality imbalance neurotransmitter, increase of

serotonin, dopamine. So the patient needs psychopharmacology

PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION) To reduce 50% the symptoms :

• Often forius anger• shout• Irritability Poor utilization of leisure time Can’t socialize with others anymore Sleep disturbances Loss of appetites

Response Remission Recovery

RESPONSE PHASE

Target therapy : 50% decrease of symptoms

Emergency departmentInj Diazepam 5 mg IV (sedation) Inj Lodomer Inj. 1 amp. IM

Maintenance Resperidon tab 2x5mgPLAN : ECT

Re-assess patient

REMISSION PHASE

Target therapy : 100% remission of symptom

Inpatient management Continue the pharmacotherapy: resperidon tab 2x5 mg Improving the patient quality of life :

Teach patient about his social & environment (interact with his family, socialize with his neighbor or friends, find a hobby to do on his spare time, and find a job that fits him well.)

Outpatient management Pharmacotherapy Psychosocial therapy

RECOVERY PHASE

Continue the medication, control to psychiatric

Rehabilitation : - Help patient to interact normally with his

family, friends, and neighbor- Family education

Thank you