Morning Report Reagan 1 Okt 2014

SUPERVISOR dr. Sabar P. Siregar, Sp.KJTuesday 30th September 2014

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PATIENTS IDENTITYName : Mrs. SSex: FemaleAge : 25 years oldAddress : Condon, Temanggung, Jawa Tengah Occupation : UnemployedMarital State : Married

RELATIVEs IDENTITY

IIIName AgeAddressOccupationEducationRelation with patient Duration of Relationship

Strength Mr. NR32 y.oCondon, TemanggungEmployer (in Jakarta)Senior High SchoolHusband

7 years

strong Mrs. P58 y.oTemanggungFarmer- Mother

25 years

strong

The Reason Patient was Brought to Emergency Room

Patient has been : Day dreamingPointless talkLaugh by herselfCry by herself

STRESSOR

2 years ago, A house that Inherited by her father in law, suddenly sold by her brother in law without her and her husband consentLast Week Ask by her father about motorcycle document (BPKB), when her husband wasnt at home

Present History of ilness In 2012, A house that Inherited by her father in law, suddenly sold by her brother in law without her and her husband consent, then she shocked and start cries by herself, pointless talk, and laugh by her self, and her husband brought her to RSJ Magelang, and she treated as out patient. Shes not routinely controlled to RSJ, and only take her medication when she has a complain, in daily routine the patient can do all the household stuff.A few month later, She didnt sleep for one week and went to midwife and prescribe medicine for sleep. But still can do all the household stuff as usual. She isnt look exhausted because of didnt sleep.

DAY OF ADMISSIONBrought to hospital by his husband and father, because of:Day dreamingTalk by herselfCry by herselfPointless talk

Last 5 days patientAsk by her father about motorcycle document (BPKB), when her husband wasnt at home

Riwayat psikiatri ada apabila setiap muncul berbeda dengan yang sekarang (kembali ke premorbid atau mendekati normal)*

Progression of DisorderSymptom20122014Role of function

GAMBAR YANG BENERR*

Prenatal & PerinatalPrenatalWanted pregnancyMother didnt complain any medical illness (anemia, infection, hypertension, DM)Prenatal care has given by midwifeWhen her mother pregnant she was happy over all

Perinatal female baby, spontaneous crying, normal birth weight (3000 gr) , aterm, from 32 y/o mother P4A0, in midwifes clinic

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

PsychomotorPatient could walk (9-12 months old) when she was 2 years oldThere was no delay in other psychomotor aspect (such as tilting the body, supine to prone, sitting, standing, smiling, holding her own hand, scoop up object, holding pencil and pilling up two objects)PsychosocialThere was no delay in psychosocial aspect (such as replying to smile, smiling when seeing interesting object, playing cilukba, knowing her family members and pointing what she wanted without crying)CommunicationThere was no delay in communication aspect (such as bubbling, cooing, making sounds without meaning, telling 2-3 syllables without meaning and calling mama/papa)EmotionThere was no delay In emotion aspect (such as when patient playing, frightened by strangers, starting to show jealousy or competitiveness towards other, and toilet training)Patient didnt pee or defecate in her pants when she was two years oldCognitiveThere was no delay in cognitive aspect (such as copying sounds that she heard for the first time and understanding simple orders)

Her mother said that no delay in her development, she can do same thing as her sister, but her mother forget about the detail

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)Psychomotor Patient can play with her friend such as hide and seek, skipping, and engklek.

Psychosocial Patient is a sociable person, have a lot of friend

Communication Patients ability to make friends at school is fair and have few friends during childhood. No problem in communication.

Emotional Patient never get mad when she didnt get what she want, eneuresis (-)

CognitivePatients academic history was good enough, she was graduated from elementary school. But not continued because of economic problem

LATE CHILHOOD & TEENAGE PHASESexual development signs & activityPatient first menstruation when she was at 6th grade.Her only boyfriend now become her husband

Psychomotor (NO VALID DATA)No valid data on patients favourite hobbies or games, if patient involved in any kind of sport.

PsychosocialShe is sociable person. She doesn't have any problem with her family

Emotional (NO VALID DATA) No valid data on patients emotional When she was teenage

Communication Sociable person, and have many friend.

ADULTHOOD Educational History

she was graduated from elementary school, and didnt continue because of economic problemOccupational history

she was work as House maid in jakarta for 5 years, and when she was back to temanggung, her boyfriend proposed her and get married. She did well inher work. Marital Status

married , dengan pilihannya gak? Bahagia gak? Boros atau hemat?Criminal History

No criminal historySocial Activity

she is an extrovert person and she have many friends. Her relation with her boss was fine.Current Situation

she lives with her childrens and her husband who work at jakarta (once a month back to temanggung)

ERIKSONS STAGES OF PSYCHOSOCIAL DEVELOPMENT

StageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on life

FAMILY HISTORYThe patient is the 4th child and has 3 siblings, the first child was diedNo Psychiatry history in the family

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GENOGRAM

25 yr old

Lingkari hanya yang tinggal serumah, kaloperlu gambar keluarga adiknya sama om nya*

PSYCHOSEXUAL HISTORYPatient realizes that he is femaleHas interests to maleHer attitude is appropriate as a female

Economic scale ini harus keluarga inti. Atau dia sendiri*

MENTAL STATE

Mental State

30h September 2014

BEHAVIOUR HypoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStreotypyMannerismAutomatismBizarre

Command automatismMutismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia

-echopraxia : pengulangan gerakan yang sama oleh pasien meniru gerakan pemeriksa-catatonia : perilaku catatone, mempertahankan gerakan aneh-active negativisme : tahanan tanpa motivasi untuk menggerakkan (memberontak, melawan gerakan)-cataplexy : penurunan tonus otot karena konflik psikologis-stereotypy : pergerakan/pembicaraan yang terfiksasi dan berulang-ulang-mannerism : pengulangan gerakan yg tidak disadari dan menjadi kebiasaan-automatism : tindakan yang otomatis/spontan, biasanya mewakili aktivitas simbolik yang tidak disadari-bizarre : aneh -command automatism : melakukan apa yg diperintahkan secara otomatis-mutism : pasien tidak mau bicara-impulsive : dari keadaan diam lalu tiba2 melakukan sesuatu yg dia ingin dan langsung dilakukan*

ATTITUDE

IndiferrentApathyTensionDependentPassive

InfantileDistrustLabileRigidPassive negativismStereotypyCatalepsyCerea flexibilityExcited

-excited: agitated, purposeless motor activity without external stimuli*

EMOTION

DISTURBANCE OF PERCEPTIONDepersonalization (-)Derealization (-)

THOUGHT PROGRESSION

CONTENT OF THOUGHTIdea of ReferenceIdea of GuiltPreoccupationObsessionPhobia Delusion of PersecutionDelusion of ReferenceDelusion of EnviousDelusion of HipochondryDelusion of magic-mystic

Delusion of grandioseDelusion of referenceDelusion of InfluenceDelusion of PassivityDelusion of PerceptionDelusion of SuspiciousThought of EchoThought of InsertionThought of withdrawalThought of Broadcasting

FORM OF THOUGHTRealisticDereisticNon RealisticAutismCannot be evaluated

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SENSORIUM AND COGNITION

PHYSICAL STATEConsciousness : compos mentis

Vital sign Blood pressure: 110/70 mmHg, adult cuff, left handedPulse rate : 74 bpm, regularTemperature : AfebrileRR: 18 x/mnt, thoracoabdominal

REVIEW SYSTEMHead : normocephali, mouth deviation (-)Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocoreNeck : normal, no rigidity, no palpable lymph nodesThorax

Cor : S 1,2 regular, no murmur heardLung : vesicular sound, wheezing -/-, ronchi-/-Abdomen : Pain (-) , normal peristaltic, tympany sound Extremity : Warm acral, capp refill

RESUMEA female, appropriate to her age, completely clothed, fair appearance

Reason to be brought to hospital are:Day dreamingPointless talkLaugh by herselfCry by herself

Affect: inapropiate, labilMood: elevatedBehaviour: normoactiveAttitude: labilPerception: Hallucination of auditory (+), visual (+)Thought Progression: Remming, tangensial, loose assiciationForm of Thought: non realisticContent of thought: idea of guiltPatients response to question: poorImpaired insight

Day dreamingPointless talkLaugh by herselfCry by herselfPoor Spare time management for child and husbandCan not communicate well with other

DAY OF ADMISSION

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SyndromeIdea of guilt Hallucination of auditory (+), visual (+)Remming, tangential, loose association

Labile, Inappropriate affectElevated moodHistory decrease of sleep ( one week)

Psychotic syndrome

Manic syndrome

DIFFERENTIAL DIAGNOSISF20.0 Schizophrenia ParanoidF25.0 Schizoaffective manic typeF25.2 Schizoaffective Mixed Type

MULTIAXIAL DIAGNOSISAxis I: F20.0 Schizophrenia paranoidAxis II: delayed diagnosisAxis III: no diagnosisAxis IV: Problem with economy and family her father ask for motorcycle document BPKB which lent to her, which is that document was mortgaged by her. Axis V : GAF admission 40-31

Patients problemsBiological problemPostive symptomps because of amount of dopamine in the postsinaps neuronPsychological problemsShe have economic problem with her family and her family in lawSocial ProblemShe cant communicate with others, leisure time with family is diminished

MANAGEMENTMorning ReportFriday September 26th, 2014

PLANNING MANAGEMENTInpatient (hospitalization):Day dreamingPointless talkLaugh by herselfCry by herself

-Response therapy : hilangnya gejala 50%-Remission : Pulih 100% dalam 4-9bulan-Recovery : Pulih 100% dalam 1 tahun-Recurrence : Kambuh di recovery-Relapse : kambuh di awal/akhir remisi*

Target therapy : 50% decrease of symptoms

Emergency departmentDiazepam inj 5 mg iv (for sedative and muscle relaxant)Inj. Haloperidol 5 mg i.m ( to decrase positive symptom in this patient)

MaintenanceHaloperidol 5 mg po 2dd1

Re-assess patient

Response Phase

Haloperidol 5mg IM kalo gejala positif menonjolRPD kalo gejala negatifECT gaduh gelisah, mutisme*

Target therapy : 100% remission of symptom

Inpatient managementRisperidone 2mg 1ddI (decrease the side effect for long-term antypsycotic usage) Improving the patient quality of life : Teach patient about her social & environment (interact with her family and child, socialize with her neighbor or friends, find a hobby to do on her spare time)

Outpatient managementPharmacotherapyPsychosocial therapy

Remission Phase

Continue the medication, control to psychiatric

Rehabilitation :

Help patient to find a hobby,Help patient to interact normally with her family and neighborFamily educationRecovery Phase

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Family educationAll people have a chance to have psychiatric problemPsychiatric problem caused by multifactorialMost of psychiatric problem cause by imbalance of neurotrasmitter in brainPsychiatric symptom can be controlled by drugs Treat patient as a normal personPlease, only help patient if she/he really need help.Dont ask patient to understand the family situation, but the family must understand the patient situation. Dont get easily angered to the patient.

Thank You

*Riwayat psikiatri ada apabila setiap muncul berbeda dengan yang sekarang (kembali ke premorbid atau mendekati normal)*GAMBAR YANG BENERR*

*Lingkari hanya yang tinggal serumah, kaloperlu gambar keluarga adiknya sama om nya*Economic scale ini harus keluarga inti. Atau dia sendiri*-echopraxia : pengulangan gerakan yang sama oleh pasien meniru gerakan pemeriksa-catatonia : perilaku catatone, mempertahankan gerakan aneh-active negativisme : tahanan tanpa motivasi untuk menggerakkan (memberontak, melawan gerakan)-cataplexy : penurunan tonus otot karena konflik psikologis-stereotypy : pergerakan/pembicaraan yang terfiksasi dan berulang-ulang-mannerism : pengulangan gerakan yg tidak disadari dan menjadi kebiasaan-automatism : tindakan yang otomatis/spontan, biasanya mewakili aktivitas simbolik yang tidak disadari-bizarre : aneh -command automatism : melakukan apa yg diperintahkan secara otomatis-mutism : pasien tidak mau bicara-impulsive : dari keadaan diam lalu tiba2 melakukan sesuatu yg dia ingin dan langsung dilakukan*-excited: agitated, purposeless motor activity without external stimuli*

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*-Response therapy : hilangnya gejala 50%-Remission : Pulih 100% dalam 4-9bulan-Recovery : Pulih 100% dalam 1 tahun-Recurrence : Kambuh di recovery-Relapse : kambuh di awal/akhir remisi*Haloperidol 5mg IM kalo gejala positif menonjolRPD kalo gejala negatifECT gaduh gelisah, mutisme*

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