MORNING REPORTSaturday, 22thMarch

2014

SUPERVISOR dr. Sabar P. Siregar,

Sp.KJ

Identity

Name : Mr. UY Age : 28 years old Gender : Male Address : Petanahan,

Kebumen Occupation : - Marriage status : Divorced Last education : JHS

Name : Mr. B Age : 46 years old Relation : Elder Brother

GUARDIANPATIENT

Talking-singing-shouting non stop too much

The reason patient was brought to the hospital

STRESSOR

? ?

?

PAST HISTORYThe first time admitted to RSJS was because of being violent, getting angry, and destroying things. He was then diagnosed F20.3. he was admitted to RSJS for about only 1 week, and he ran away from RS.

2013

- Can work again but very rarely- He utilized his leisure time hanging out

with his friend, and they give him alcohol and drugs again

- He took goodcare of himself about so-so

• 2 months before he was brought, the patient admitted again to RSJS for the very same reason. After 1 month treated, he ran away again from RSJS.

• 2 weeks before he was brought, he started talking-singing-shouting non stop so the others was feeling disturbed. He also couldnt sleep and often wandered around randomly.

He cant do his usual work Poor utilization of leisure time hanging out

with friends, drinking and taking drugs He could take care of himself

March 2014PRESENT HISTORY

• Patient kept talking-shouting-singing non stop and uttering random words.•And he was then brought to RSJS Magelang

Day of admission

Brought to RSJS ER

by his elder

brother

The patient was admitted to the RSJS Magelang for TWO times

(2013, and January 2014) because of undifferentiated

schizophrenia

Psychiatric history

• Head injury (-)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)• History of admission (-)

General medical history

•Drugs consumption (+)

• Alcohol consumption (+)

• Cigarette Smoking (+)

Drugs, alcohol

abuse, and smoking history

Patient’s family can not recall any impairment on growth and development. Other milestone can not be assessed properly.

Psychomotoric (no valid data)There is no valid data when patient:

• first time lifting the head (3-6 months) (rolling over (3-6 months) • Sitting (7-8 months) • Crawling (6-9 months) • Standing (6-9 months) • walking-running (16 months) • holding objects in her hand (3-6 months) • putting everything in her mouth (3-6 months)

Psychosocial (no valid data) Parents can not recall the times when 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)

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Communication (no valid data) • They were forgot on when patient started saying words 1 year like

‘mom’ or ‘dad’. (1 year old)

Emotion (no valid data) • They were forgot 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) • They were forgot on which age the patient can follow objects,

recognizing her mother, recognize her family members.• They were forgot on when the patient first copied sounds that were

heard, or understanding simple orders.

Psychomotor (no valid data) forgot on when patient’s first time playing hide and seek or if patient ever

involved in any kind of sports Psychosocial (no valid data)forgot about patient’s social relation.

Communication (no valid data) forgot regarding patient ability to make friends at school and how many

friends patient have during his school period Emotional (no valid data)

forgot on patient’s adaptation under stress, any incidents of bedwetting were not known.

Cognitive (no valid data)forgot on patient’s cognitive.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Sexual development signs & activity (no valid data)Patient first’s wet dreaming, etc.

Psychomotor (no valid data) There is no valid data on patient’s hobbies

Psychosocial Parents claimed that he had some friends.

Emotional (no valid data) There is no valid data on patient’s reaction on playing, scared,

showed jealously or competitivenessCommunication

Patient can communicate well.

LATE CHILDHOOD & TEENAGE PHASE

Stage Basic Conflict Important EventsInfancy(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

Erikson’s stages of psychosocial development

Family history

Patient is the last child with four siblinga Psychiatry history in the family (-)

Genogram

Patient Psychiatric Disorder

Patient knows that he is male, his behavior is appropriate for female, he is attracted to woman.

He has been married for ?? years and has 2 children

Psychosexual history

Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : valid• Autoanamnesis : valid

Progression of disorder

Symptom

Role function

2004 2014

Mental State(Thursday 20th March 2014)

Appearance • A man, appropriate to his age, completely

clothedState of Consciousness• Clear

Speech• Quantity : increased• Quality : decreased

Behaviour

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

•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•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• Talkative

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 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• Idea of suicide

Form of thought

•Realistic•Non Realistic•Dereistic•Autistic

Sensorium and Cognition Level of education : Can’t be assessed General knowledge : Can’t be assessed Orientation of time : Good Orientations of place : Can’t be assessed Orientations of peoples : Good 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: Good

Impulse control when examined• Self control: Enough

Insight • Impaired insight• Intellectual Insight• True Insight

Internal StatusConsciousnes : compos mentisVital sign :

◦Blood pressure : 130/80 mmHg◦Pulse rate : 120 x/mnt◦Temperature : Afebris◦RR : 24 x/mnt, regular

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”, tremor (-)

Neurological exam : not examined

RESUMEDAY OF ADMISSION

Symptoms

Talking-shouting-singing randomly non-stopWandering aroung randomly

Mental Status• Behavior : not cooperative

• Affect: inappropriate, labile

• Mood: euphoric

• Orientation: difficult to assess

• Form of thought: autistic, non realistic

• Progression of thought: logorrhea, word salad, neologisme, sound association

• Insight: impaired

Impairment

Disturbance of role function

Differential Diagnosis

F20.3 Undifferentiated SchizophreniaF25.0 Schizoaffective Manic Type

Multiaxial DiagnosisAxis I : F31.4 Bipolar Disorder with Depressive

Episode and Psycotic SignsAxis II : no diagnosisAxis III : no diagnosisAxis IV :Axis V : GAF on admission

1. Problem about patient’s family

2. Problem about social economyhis economic condition is average

3. Problem about patient’s biological stateIn Schizoaffective patient, there is abnormal balancing of the neurotransmitter (increasing of dopamine) which has the contribution for the positive symptoms : have hallucination. We need pharmacotherapy for re-balancing the neurotransmitter

Problem related to the patient

Inpatient (hospitalization)

Purpose of hospitalization is to decrease the symptoms : talking non stop Wandering around

PLANNING MANAGEMENT

Response Remission

Recovery

Target therapy : 50% decrease of symptom (wandered around, hallucination)

Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m., Inj. Diazepam 10mg im. (wandered around, hallucination)

MaintenanceQuetiapine 1x200 mg (morning)Clozapine 1x50 mg (night)

Suggest : Re-assess patientSupportive therapy from family

RESPONSE PHASE

Target therapy : 100% remission of symptom within 4-9 months (wandered around, hallucination)

Inpatient management1. Continue the pharmacotherapy: Quetiapine 1x200 mg and Clozapin 1x50 mg po2. Improving the patient quality of life :

Teach patient about his social & environment(take care of children, moping, clean the floor,

washing the dishes, etc)

Outpatient management1. Pharmacotherapy2. Psychosocial therapy

REMISSION PHASE

Target therapy : 100% remission of symptom within 1 year.(wandered around, hallucination)

RECOVERY PHASEContinue the medication, control to psychiatric

Rehabilitation : help patient to got & apply his skill

Family education

Thank you~ :*