Morpot 27 Maret

MORNING REPORTThursday, 27thMarch

2014

SUPERVISOR dr. Sabar P. Siregar,

Sp.KJ

IDENTITY

Name : Ms. T Age : 26 years old Gender : Female Address : Cilacap Occupation : Unemployed Marriage status : Not Married

Yet Last education : JHS

Name : Mrs. S Age : 53 years old Relation : Mother

GUARDIAN

PATIENT

Talking and singing by herself, and

easily got angry

The reason patient was brought to the hospital

STRESSOR

unclear

PRESENT HISTORY

3 years before, after dismissed from Banyumas Hospital, the patient got to work again as housemaid in Jakarta for a year, and got back to Cilacap because of not feeling comfort in Jakarta. Up till now, she was not working at all, and doing nothing at home.

She was oftenly daydreaming,She didnt take her routine medication.

2011

- She didnt feel like to work at home.- She utilized her leisure time doing nothing- She barely took goodcare of herself

• 3 months before, the patient started unable to sleep, didn’t

work at all at home, and occasionally easily got angry towards her neighbors.

• She threw away her foods whenever she was given food.• She often talk to herself more than before.

She cant do her usual work Poor utilization of leisure time She barely take care of herself

2014 PRESENT HISTORY

• Patient kept talking by herself• Easily got angry

Day of admission

Brought to RSJS ER

by her mother

The patient was admitted to the Psychiatric Unit of Banyumas

Hospital at 2011 because she was oftenly talking to herself.

Psychiatric history

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

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’s menarche, etc.

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

Psychosocial The patient prefers to be at home than playing outside with 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 2nd child with two siblings Psychiatry history in the family (+) on her

grandmother’s brother

Genogram Patient Psychiatric Disorder

Patient knows that she is female, her behavior is appropriate for female, she is attracted to man.

Psychosexual history

Socio-economic history

• Economic scale : average to low

Validity

• Alloanamnesis : valid• Autoanamnesis : invalid

Progression of disorder

Symptom

Role function

2011 20142013

Mental State

(Thursday 27th March 2014)

Appearance • A woman, appropriate to her age, completely

clothedState of Consciousness• Cloudy

Speech• Quantity : decreased• 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• Disphoric• Irritable• Agitation• Can’t be assesed

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 (-)

Cant be assessed

Thought progression

Quantity

• 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 : Can’t be assessed Orientations of place : Can’t be assessed Orientations of peoples : 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: Bad

Insight • Impaired insight• Intellectual Insight• True Insight

Internal Status

Consciousnes : compos mentisVital sign :

◦Blood pressure : 130/70 mmHg◦Pulse rate : 112 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 by herself

Easily got angry to her NBs

Unable to start sleeping

Mental Status• Behavior : not

cooperative

• Attitude : tension, distrust

• Affect: restrictive• Mood: irritable

• Form of thought: autistic

• Progression of thought: Mutism, poverty of speech

• Perception: delusion of suspicious

• Insight: impaired

ImpairmentDisturbance of role function She cant do her

usual work Poor utilization

of leisure time She barely take

care of herself

Differential Diagnosis

F20.0 Paranoid SchizophreniaF25.1 Schizoaffective Depressive TypeF32.2 Severe Depressive Disorder with

Psycotic Sign

Multiaxial Diagnosis

Axis I : F20.0 Paranoid SchizophreniaAxis II : delayed diagnosis Axis III : no diagnosisAxis IV : stressor unclearAxis V : GAF on admission 30-21

1. Problem about patient’s familyunclear

2. Problem about social economyThe socioeconomic level is at average

3. Problem about patient’s biological stateIn Schizophrenic patient, there is abnormal balancing of the neurotransmitter (increasing of dopamine) which has the contribution for the symptoms : talking by herself, delusion of suspicious. We need pharmacotherapy for re-balancing the neurotransmitter

Problem(s)related to the patient

Inpatient (hospitalization)

Purpose of hospitalization is to decrease the symptoms : Talking by herself delusion of suspicious easily got angry

PLANNING MANAGEMENT

Response Remission

Recovery

Target therapy : 50% decrease of symptom (talking to herself, delusion of suspicious)

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

MaintenanceRisperidone 2 x 2 mg

Suggest : Re-assess patientSupportive therapy from family

RESPONSE PHASE

Target therapy : 100% remission of symptom within 4-9 months (talking to herself, delusion of suspicious)

Inpatient management1. Continue the pharmacotherapy:

Risperidone 2 x 2 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

REMISSION PHASE

Target therapy : 100% remission of symptom within 1 year (talking to herself, delusion of suspicious)

RECOVERY PHASEContinue the medication, control to psychiatric

Rehabilitation : help patient to got & apply his skill

Family education

Thank you~ :*