SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT
Saturday 24
th
May 2014
Patient Identity
Autoanamnesis
Name : Ms. S
Sex : Female
Age : 27 years old
Address : Purworedjo
Occupation : No job
Marital State : Single
Alloanamnesis
Name : Ms. L
Sex : Female
Age : 51 years old
Relation : Mother



Reason patient was brought to emergency
room
Patient was mad without reason till trying
for kill, talking to herself, unable to sleep
Stressor
Unclear
Present History
She couldnt utilize her
leisure time
She wont eat
She didnt socialize with
neighbor
May 2014
She mad without any
reason, irritable and
slamming things
She couldnt utilize her
leisure time
She didnt socialize with
her neighbor
April 2014
Patient start to have a
symptom like was
talking to herself, angry
without any reason till
trying for kill, unable to
sleep
Day of Admission
24
th
May 2014
Patient brought with the
complaints of:
Angry without any reason
Talking to herself
Unable to sleep
Slamming things

Brought to
hospital by her
Mother

She cant doing her daily activity,
Poor utilization of leisure time
he couldnt socialize with friends
The patient didnt take
any medicine
PSYCHIATRIC HISTORY
She was hospitalized in RSJS Magelang
in 2001 and 2007
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 (NORMAL)
- Patients growth and development such as:
first time lifting the head (3 months)
rolling over (5 months)
Sitting (8 months)
Crawling (8 months)
Standing (9 months)
walking-running (12 months)
holding objects in her hand(5 months)
putting everything in her mouth(3 months)

Psychosocial (NORMAL)
- Patient :
started smiling when seeing another face (3 months)
startled by noises(4 months)
when the patient first laugh or squirm when asked to play, nor
playing claps with others (7 months)

Communication (NORMAL)
- Patient started bubbling. (8 months)

Emotion (NORMAL)
- Patients reaction when playing, frightened by strangers (3 month),
when starting to show jealousy or competitiveness towards other and
toilet training (2 years).

Cognitive (NORMAL)
- The patient can follow objects, recognizing his mother, recognize his
family members. (1-2 years)
- The patient first copied sounds that were heard, or understanding
simple orders. (1-2 years)
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Psychomotor (NORMAL)
Patients first time playing hide and seek or if patient ever involved in
any kind of sports. (4-5 years)
Psychosocial (NORMAL)
Patient had a normal psychosocial.
Communication (NORMAL)
Patient had ability to make friends at school.
Emotional (NORMAL)
Patient had a good emotional.
Cognitive (NORMAL)
Patients cognitive same with others.
LATE CHILDHOOD & TEENAGE
PHASE
Sexual development signs & activity (NORMAL)
Patient first experience of menarche, etc. (11 Years)

Psychomotor (NORMAL)
Patient had any favourite hobbies or games, if patient involved in any kind of
sports.

Psychosocial (NORMAL)
Patient psychosocial.

Emotional (BAD)
Patient had bad emotional.

Communication (NORMAL)
Patient had ability to make friends at school.
ADULTHOOD
Educational History
She didnt finish senior high
school.

Occupational history
She had no job.

Marital Status
She hasnt married

Criminal History
No criminal history




Social Activity
She was a happiness girl.
She joined organization.

Current Situation
She lives with her mother.
She always angry if got
separated with her mother.
Her mother hadnt job and
had financial problem.
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
PSYCHOSEXUAL HISTORY
Patient realizes that she is a female, and interests to a male.
Her attitude is appropriate as a female.
Socio-economic history
Economic scale: Low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
FAMILY HISTORY
Patient is the only child.

Psychiatry history in the family (-)

Genogram
MALE FEMALE PATIENT
Progression of Disorder
Symptom
Role Function
2001
May 2014 2007
Appearance
A female, appropriate to her age, completely
clothed
State of Consciousness
Stupor
Speech
Quantity : Decreased
Quality : Decreased
Mental State
24
th
May 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 (+) wayang
music
Visual (+) ghost
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
Delusion of Suspicious
Thought of Echo
Thought of Insertion &
withdrawal
Thought of Broadcasting
Form of Thought
Realistic
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition
Level of education : didnt go to school
General knowledge : bad
Orientation of time : cant be accessed
Orientations of place : cant be accessed
Orientations of people : cant be accessed
Orientations of situation : cant be accessed
Working/short/long memory: cant be accessed
Writing and reading skills : cant be accessed
Visuospatial : cant be accessed
Abstract thinking : cant be accessed
Ability to self care : cant be accessed

Impulse control when
examined

Self control: bad
Patient response to
examiners question:
bad
Insight

Impaired insight
Intellectual Insight
True Insight
Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 120/80 mmHg
Pulse rate : 106 x/mnt
Temperature : Afebrile
RR : 20 x/mnt
Review System
Head : normocephali, mouth deviation (-)
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.
Neurological exam : not examined
Symptoms Mental Status
Impairment

-Behaviour : Active negativism,
Aggresive
-Attitude: Infantile
- Mood: Cant be assesed
- Affect: blunted
- Perception: Auditory, visual
hallucination
- Thought Progression: talk active,
confabulation
- Form of Thought: Non-realistic
- Content of thought: Delusion of
suspicious
- Patients response to question:
bad
- Impaired insight


- Talking to
herself
- Angry
without any
reason
- Unable to
sleep
She cant do her
daily activity,
Poor utilization
of leisure time
He couldnt
socialize with
friends
A woman, appropriate with her age, clothes completely
Differential Diagnosis
F20.0 Schizophrenia Paranoid
F20.1 Schizophrenia Hebefrenik

Multiaxial Diagnosis
Axis I : F20.0 Schizophrenia Paranoid
Z91.1 Disobeyed of medication
Axis II : Z03.2 No Diagnose
Axis III : No Diagnose
Axis IV : Unclear
Axis V : GAF admission 20-11
Problem related to the patient

1. Problem about patients life
Patient couldnt manage scedule, she didnt finish her senior
high school because her sick. She always angry if got
separated with her mother. She hadnt father figure. She
refuse to take medicine.

2. Problem about patients biological state
The simplest formulation of the dopamine, serotonin and
norepinephrine hypothesis of schizophrenia posits that
schizophrenia results from too much dopaminergic,
serotonin and norepinephrine activity.

PLANNING MANAGEMENT
In patient (hospitalization)
To reduce 50% the symptoms :

Talking to himself
Angry without any reason
Unable to sleep
Visual and auditoric hallucinations
Delusion of suspicious
Response Remission Recovery
RESPONSE PHASE
Target therapy : 50% decrease of symptoms

Emergency department
Haloperidol 5mg i.m
Diazepam 10mg i.v

Maintance
Haloperidol 2x5mg

Planning
ECT

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

Inpatient management
1. Continue the pharmacotherapy: maintenance Haloperidol
2x5mg
2. ECT plan
3. Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor, get a new
job, find a hobby to do 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 and
neighbor

- Family education :
- explain to the family about the mental disorder and
the treatment.
- Educate the family to support not to exile the
patient.
- Ask the family to monitor patient progress and make
sure the patient take medicine as prescribe.