SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT
Monday 2
nd
June 2014
PATIENT IDENTITY
Name :
Mrs. SN
Sex :
female
Age :
33 years old
Address :
Kebumen
Occupation :
unemployed
Marital State :
Married
General education : primary school

RELATIVES IDENTITY
Name : Mr. S
Sex : Male
Age : 58 years old
Relation : father
REASON PATIENT WAS BROUGHT TO
EMERGENCY ROOM
Patient was angry without any reason and
broke anythings.
STRESSOR
Unclear
PRESENT HISTORY
Angry without reason,
anxious, wander
Hospitalize in RSJ
2010
she didnt go to work
she couldnt utilize his leisure time
she didnt socialize with neighbor
she was hospitalized
I : for 1 months in 2010
II : for 1 months in 2012
III : for 1 months in 2013
IV : for 1 months in 2014
DAY OF ADMISSION
02 June 2014

Brought to
hospital by her
father

Poor utilization of leisure time
she cant do his daily activity.
she couldnt socialize with friends
she cant go to work
Poor grooming
Patient brought with the
complaints of:
Angry without reason
unable to sleep
Attack his husband
talking to himself

PSYCHIATRIC HISTORY
No Psyciatric History
General
medical history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol
abuse history and
smoking history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (-)
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric
- There were no valid data on patients growth and development such as:
first time lifting the head (3-6 months)
rolling over (3-6 months)
Sitting (6-9 months)
Crawling (6-9 months)
Standing (6-9 months)
walking-running (9-12 months)
holding objects in her hand(3-6 months)
putting everything in her mouth(3-6 months)

Psychosocial
- There were no valid data on which age 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
- There were no valid data on when patient started bubbling. (6-9 months)

Emotion
- There were no valid data of patients reaction when playing, frightened
by strangers, when starting to show jealousy or competitiveness
towards other and toilet training.

Cognitive
- There were no valid data on which age the patient can follow objects,
recognizing his mother, recognize his family members.
- There were no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Psychomotor
No valid data on when patients first time playing hide and seek or if
patient ever involved in any kind of sports.
Psychosocial
No valid data regarding patient psychosocial.
Communication
No valid data regarding patient ability to make friends at school and
how many friends patient have during his school period
Emotional
No valid data on patients emotional.
Cognitive
No valid data on patients cognitive.
LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity
No data on when patient first experience of menarcher

Psychomotor
No data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.

Psychosocial
No valid data regarding patient psychosocial.

Emotional
No valid data on patients emotional.

Communication
No valid data regarding patient ability to make friends at school and how
many friends patient have during his high school period
ADULTHOOD
Educational History
finished primary school, she
is average student in the
class

Occupational history
she never worked

Marital Status
married and have one child.
She is a good wife



Criminal History
No Criminal history.

Social Activity
Before she was sick, she was
friendly and had many
friends

Current Situation
She lives with her parents.
She become the burden of
the family
ERIKSONS STAGES OF PSYCHOSOCIAL
DEVELOPMENT
Stage Basic Conflict Important Events
Infancy
(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 4
th
child of 6 siblings

Her brother and uncle have the
sama complaint in the family
Genogram
MALE FEMALE Patient
PSYCHOSEXUAL HISTORY
.
Patient realizes that she is a female, and interest to a
male. Her attitude is appropriate as a female
Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
Progression of Disorder
Symptom
Role Function
2010
2/6/2014
2013 2012
Appearance
A female, appropriate to her age, completely
clothed
State of Consciousness
Clear
Speech
Quantity : Normal
Quality : Normal
MENTAL STATE
02
ND
JUNE 2014
BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre
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
Excited
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant 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 (-)
Thought Progression
Quantity

Logorrhea
Blocking
Remming
Mutism
Talk active
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
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
Thought of Echo
Thought of Insertion &
withdrawal
Thought of Broadcasting
Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition
Level of education : primary school
General knowledge : good
Orientation of time :good
Orientations of place :good
Orientations of people : Good
Orientations of situation :good
Working/short/long memory : good
Writing and reading skills :good
Visuospatial : good
Abstract thinking : good
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
Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 120/90 mmHg
Pulse rate : 92 x/mnt
Temperature : 36.5 C
RR : 20 x/mnt
Head : normocephali, mouth deviation (-)
Ears : normotia/normotia, sekret-/-, pain -/-
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, motoric strength
Symptoms Mental Status
Impairment

-
- Angry
without
reason
- unable to
sleep
- Attack his
husband
- talking to
himself

she cant do his daily
activity.
she couldnt
socialize with
friends
she cant go to work
Decrease appetite
Male 31 years old, appropiate to his age, completely clothed
- Behavior: hypoactive
-Thought of Progression:
talkactive
- Form of thought : non
realistic

Differential Diagnosis

F20.0 Skizophrenia Paranoid
F20.3 Skizophrenia Undifferentiated
Multiaxial Diagnosis
Axis I : F20.0 Skizophrenia Paranoid
Axis II : Z03.2 No Diagnose
Axis III : none
Axis IV : unclear
Axis V : GAF admission 40-31
PROBLEM RELATED TO THE PATIENT

1. Problem about patients life
- Angry without reason, unable to sleep, Attack his husband,
talking to himself, life with her parents

2. Problem about patients biological state
In Schizophrenic patient, there is abnormal balancing of the
neurotransmitter (increasing of dopamine) which has the
contribution for the positive symptoms : have hallucination
and delusion. We need pharmacotherapy to rebalance the
neurotransmitter.

PLANNING MANAGEMENT


Inpatient (hospitalization)
To reduce 50% the symptoms :
Angry without reason
Unable to sleep
Attack his husband
Talking to himself
Life with her parents



Response Remission Recovery
RESPONSE PHASE
Target therapy : 50% decrease of symptoms

Emergency department
Inj Diazepam 5 mg IV (sedation)
Inj Haloperidol 1 amp. IM

Maintanance
Haloperidol Tab 2x5mg (anti-psykotic)



Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom

Inpatient management
1. Continue the pharmacotherapy: maintenance Haloperidol
2x5mg
2. Improving the patient quality of life :
Teach patient about his social & environment
(interact with his family, socialize with his neighbor or friends,
find a hobby to do on his spare time)

Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
RECOVERY PHASE
Target therapy : 100% remission of symptom within 1 year.
- Continue the medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact normally with
her family, his friends and neighbor
- Family education such as tell his family
about patient condition and how much
familly support affect the success of
therapy