MORNING REPORT

Monday, 17thMarch 2014

SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

Identity

• Name : Mr. S• Age : 32 years old• Gender : Male• Address : Grabag,

Magelang• Occupation : Unemployed • Marriage status : Single• Last education : Junior High School

• Name : Mr. MS• Age : 65 years old• Relation : Father

GUARDIANPATIENT

The reason patient was brought to the hospital• Keep kicking the door’s house• Easily got angry

STRESSOR

Unclear

PRESENT HISTORYPatient was graduated from junior high school and wanted to continue at Taruna Nusantara High School but he was failed in the admission test. Since then, he changed behaviour : • Easily got angry• Attack people• Destroy things

2005

Since then he often

admitted to the RSJS

Magelang (9 times)

- He did not continue studying- He did not socialize with neighbours- He poorly utilize his leisure time- He did not took goodcare of himself

After discharged from hospital, he continued : •Could not sleep•Wandering around in the early morning to buy cigarette.•Often get angry for unknown reason•Saw her sister shadow insulting him and taunt him to fight

He didn’t want to work Poor utilization of leisure time He could take care of himself

February 2014

•Keep kicking the door•Get angry for unknown reason•Saw shadow taunt and insulting him•Cannot sleep at appropriate time•Wandering around in early morning

Day of admission

Brought to RSJS ER

by his father

He didn’t want to work Poor utilization of leisure time He could take care of himself

The patient was admitted to the RSJS Magelang for nine times because of paranoid

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

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 experience of wet dreaming, etc.Psychomotor

Patient had hobby (playing football)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.

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 fifth child with four siblings• Psychiatry history in the family (-)

Genogram

Patient

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

Psychosexual history

Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : valid• Autoanamnesis : not valid

Progression of disorder

Symptom

Role function

2005 2014

Mental State(Monday 17th 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

• Coherence• 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 : Good General knowledge : Good Orientation of time : Good Orientations of place : Good Orientations of peoples : Good Orientations of situation : Good Working/short/long memory: Good Writing and reading skills : Good Visuospatial : - Abstract thinking :- Ability to self care :Good

Impulse control when examined• Self control: Enough• Patient response to

examiners question: Good

Insight • Impaired insight• Intellectual Insight• True Insight

Internal StatusConsciousnes : compos mentisVital sign :

◦Blood pressure : 120/80 mmHg◦Pulse rate : 98 x/mnt◦Temperature : Afebris◦RR : 20 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

Mental Status

• Mood: irritable, inappopriate.

• Talk active

• Loosening of association

• Auditory and visual hallucination

• Dellusion of magic-mystic, suspicious, and grandiose

• Impaired insight

Impairment

He didn’t want to workPoor utilization of leisure time

•Keep kicking the door•Get angry for unknown reason•Saw shadow taunt and insulting him•Cannot sleep at appropriate time•Wandering around in early morning

Differential DiagnosisF20.0 Paranoid SchizophreniaF25.0 Schizoaffective Manic Type

Multiaxial DiagnosisAxis I :F20.0 Paranoid SchizophreniaAxis II : skizotipal Axis III : -Axis IV : unclearAxis V : GAF on admission 30-21

Problem related to the patient• 1. Problem about patient’s family

He was failed to continue his study at high school

• 2. Problem abour social economyhis economic condition is average

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

PLANNING MANAGEMENT

Inpatient (hospitalization)Purpose of hospitalization is to decrease

the symptoms :Wandering around, Destroy things

Response Remission

Recovery

RESPONSE PHASE

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

Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m.because the patient has positive symptom(wandered around, destroy things , hallucination, delusions)

MaintanceHaloperidol 2x5mg per oral

Suggest : ECTRe-assess patient

REMISSION PHASETarget therapy : 100% remission of symptom within 4-9 months (wandered around, destroy things, hallucination, delusions)

Inpatient management1. Continue the pharmacotherapy: Haloperidol 2x5 mg po2. Improving the patient quality of life : •teach patient to care about himself (took a bath, toothbrushing)Teach patient about his social & environment( moping, clean the floor, washing the dishes)

•Outpatient management1. Pharmacotherapy2. Psychosocial therapy

RECOVERY PHASE

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

Continue the medication, control to psychiatric

Rehabilitation : help patient to got & apply his skill

Family education

Thank you