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 : Unemployed• Marriage status : Divorced• Last education : JHS

• Name : Mr. B• Age : 46 years old• Relation : Eldest Brother

GUARDIANPATIENT

The reason patient was brought to the hospital

• Talking-singing-shouting non stop too much

STRESSOR

unclear

PRESENT 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 and got home by himself.He was divorced with his wife at this year because of his wife’s proposal.

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 barely took goodcare of himself

• 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 He barely take care of himself

2014PRESENT HISTORY

• Patient kept talking-shouting-singing non stop and uttering random words.

Day of admission

Brought to RSJS ER

by his eldest

brother

The patient was admitted to the RSJS Magelang for TWO times

(2013, and January 2014)

Psychiatric history

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

General medical history

•Drugs consumption (+)

• Alcohol consumption (+)

• Cigarette Smoking (+)

Drugs, alcohol

abuse, and smoking history

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

• 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)

• 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.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)• 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.

LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity (no valid data)

Patient first’s wet dreaming, etc.Psychomotor (no valid data)

There is no valid data on patient’s hobbiesPsychosocial • His brother claimed that he had some friends who

gave him drugs and alcohol.Emotional (no valid data)

There is no valid data on patient’s reaction on playing, scared, showed jealously or competitiveness

Communication Patient can communicate well.

Erikson’s stages of psychosocial development

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

Family history

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

Genogram

Patient Psychiatric Disorder

2013

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

• He has been married for ± 7 years and has 2 children

Psychosexual history

Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : invalid• Autoanamnesis : invalid

Progression of disorder

Symptom

Role function

2013 Mar 2014

Jan 2014

Mental State(Saturday 22th March 2014)

Appearance • A man, appropriate to his age,

completely clothedState of Consciousness• Cloudy

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• 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: Can’t be assessed

Impulse control when examined• Self control: Bad

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 around randomly

Mental Status

• Behavior : not cooperative

• Affect: inappropriate, labile

• Mood: euphoric

• Orientation: impaired on situation and place

• Form of thought: autistic

• Progression of thought: logorrhea, neologisme, flight of idea

• Insight: impaired

ImpairmentDisturbance of role function He cant do his

usual work Poor utilization

of leisure time He barely take

care of himself

Differential Diagnosis

F19 Mental Disorder because of Using Multiple Drug Use and Other Psychoactive Substance

F20.3 Hebefrenic SchizophreniaF25.0 Schizoaffective Manic Type

Multiaxial DiagnosisAxis I : F20.3 Hebefrenic SchizophreniaAxis II : no diagnosisAxis III : no diagnosisAxis IV : stressor primary support groupAxis V : GAF on admission 30-21

Problem related to the patient• 1. Problem about patient’s familyDominancy of his wife

• 2. Problem about social economySocial history on his childhood friends

• 3. Problem about patient’s biological stateIn Schizoaffective patient, there is abnormal balancing of the neurotransmitter (increasing of dopamine) at limbic system which has the contribution for the symptoms : talking active, neologisme, flight of idea. We need pharmacotherapy for re-balancing the neurotransmitter

PLANNING MANAGEMENT

Inpatient (hospitalization)

Purpose of hospitalization is to decrease the symptoms : Talking non stop Neologisme Flight of idea Wandering around

Response Remission

Recovery

RESPONSE PHASETarget therapy : 50% decrease of symptom (wandered around, talk active, neologisme, flight of idea)

Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m.Sedative : Inj. Diazepam 10mg im.

MaintenanceRisperidone 2 x 2 mg

Suggest : Re-assess patientSupportive therapy from family

REMISSION PHASETarget therapy : 100% remission of symptom within 4-9 months (wandered around, talk active, neologisme, flight of idea)

Inpatient management1. Continue the pharmacotherapy: Risperidone 2x2 mg2. Improving the patient quality of life :

Teach patient about his social & environment(back to work, moping, clean the floor, washing

the dishes, etc)

•Outpatient management1. Pharmacotherapy2. Psychosocial therapy

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1 year (wandered around, talking nonstop, flight of idea, neologisme)

Continue the medication, control to psychiatric

Rehabilitation : help patient to got & apply his skill

Family education

Thank you~ :*