MORNING

REPORT
Monday, January 19th 2015
Case on : Saturday. January 17th 2015
Supervisor
dr. Sabar P. Siregar, Sp. KJ

PATIENTS IDENTITY
Name
: Mrs. W
Age
: 44 years old
Gender
: female
Address
: Purworejo, Central Java
Occupation
: Unemployed
Marriage status: Widow
Last education : Senior high school
Date of admission : January 17th 2015

ALLOANAMNESIS
Obtained from
Name
:S
B
Age
: 53 years old
35 years old
Gender
: female
male
Relationship
: Sister
Brother
Duration of acquaintance : since birth
since birth

REASON BROUGHT TO THE

HOSPITAL
Patient is brought to the hospital by her family
because she was laughing alone, talking to herself,
talked a lot, talk unfocused, sometimes talk using
english speech, her speech that is not understood,
wandering, unable to sleep, very sensitive, and
difficulty eating.

PRESENT ILLNESS
The patient began to show the symptoms since 1 years ago after
she was divorce with her husband.
After that, she was talked a lot and change of her attitude and
behavior (hyperactive).
6 months later, her mother was died. And then, her symptoms
increased like talking to herself, talked a lot, and talk unfocused.
She did not go to work and her social interaction has been
decreasing since the symptoms appear.
1 Month ago, the symptoms began to get worse. She was laughing
alone, talking to herself, talked a lot, talk unfocused, sometimes
talk using english speech, her speech that is not understood,
wandering, unable to sleep, very sensitive, difficulty eating, and
she always heard a voice that is not clear in the midnight after
she was praying.
Concerning with her behavior, her sister and her brother took her
to RSJ Magelang.

PROGRESSION OF ILLNESS
1 year ago
6 months ago

1 month
before
admission

Talked a lot
Change of her attitude and behavior (hyperactive)

Talking to herself
Talked a lot
Talk unfocused
Social interaction
Productivity

Laughing alone
Talking to herself
Talked a lot
Talk unfocused, sometimes talk using
english speech
Speech that is not understood
Wandering
Unable to sleep
Difficulty eating
She always heard a voice
Very sensitive
Social interaction
Productivity

HISTORY OF PRESENT ILLNESS

Psychiatric History
She has never
been hospitalized
due to such
psychiatry
complaints

General Medical
History
Febrile seizure (-)
Epilepsy (-)
Trauma (-)

Drugs, alcohol
abuse, and smoking
history
Alcohol
consumption (-)
Smoking (-)
Drug abuse (-)

STRESSOR
Divorce
Miss her children

GENOGRAM

= Patient
= Mental Disorders
= Normal
= Died
= Abortus

FAMILY HISTORY
Her brother have a history of mental illness
Her brother have medication in RSJ Magelang

PROGRESSION OF DISORDER
sympto
m

Role
function

1 year ago

The day of
admission

HISTORY OF PERSONAL LIFE

1.

Prenatal and perinatal history

2.

Early childhood phase

3.

Intermediate childhood

: Normal (good)
: Good
: Pass in the Senior High school and

continue her study in Faculty of bussiness and management but she didnt
pass it.
4.

Late childhood

: Ever work in roof company as a secretary manager.

She was very disciplin because her father is a military person. Her Spiritual is
good.
5.

Adulthood

: She has married and she has 4 children.

She was divorce by her husband one year ago because her husband having
an affair with another girl. She is very sensitive if talk about her husband.
Her chidren follow her husband and live far away from her.

PERSONAL LIFE
FAMILY

Patient is the eleventh daughter of fifteenth siblings.

Her father passed away since she was a child.

Her mother passed away after she divorce with her husband

Her chidren follow her husband and live far away from her

At this moment, she lives with her brother.

PSYCHOSEXUAL HISTORY
Appropriate with her gender. She realizes that she is a woman.

PERSONAL LIFE
SOCIOECONOMIC HISTORY
Medium socioeconomic scale

VALIDITY
Alloanamnesis : valid

MENTAL STATE EXAMINATION

ON THE DAY OF ADMISSION (SATURDAY, JANUARY 17TH

2015, 10 AM)

Appearance
A female, looks suitable with her actual
age, wears complete clothes.

State of Consciousness
Clear

Speech
Quantity: increased
Quality : decreased

Behavior
Hypoactive

Hyperactive
Echopraxia
Catatonia
Negativism
Cataplexy
Stereotypy
Mannerism
Automatism
Command
automatism
Bizarre

Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

Tremor
Floxilation
Anergy
Dischynesia
Muscle rigidity
Bradychynesia
Khorea
Convulsion
Dystonia
Aminia

Attitude
Cooperative
Indiferrent
Apathy
Tension
Dependent
Passive

Active

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotipy
Catalepsy
Cerea flexibility
Excited

EMOTION
Mood
Hypothymic
Euthymic

Elevated
Dysphoric

Euphoria
Expansive

Irritable
Agitation
Unremarkable

Affect
Appropriate

Inappropriate
Restrictive
Blunted
Flat
Labile

DISTURBANCE OF PERCEPTION
Hallucination

Auditory (+)
Olfactory (-)
Visual (-)
Gustatory (-)
Tactile (-)
Somatic (-)

Depersonalisation (-)

Illusion

Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)

Derealisation (-)

THOUGHT PROGRESSION
Quantity

Logorrhea

Blocking
Remming
Mutism
Talkative

Quality

Irrelevant answer
Incoherence

Coherence
Flight of idea
Confabulation
Poverty of speech
Slow speech
Loosening of association
Neologisme
Circumstantiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
Unremarkable

Content of Thought
Idea

of Reference

Delusion of Grandiose

Preoccupation

Delusion of Control

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Delusion

of Persecution

Delusion of Perception

Delusion

of Reference

Thought of Echo

Delusion

of Envious

Thought Insertion

Delusion

of Hypochondriac Thought of withdrawal

Delusion

of magic-mystic

Fantasy

Thought Broadcasting
Cant be assesed

Form of Thought
Realistic

Non Realistic
Dereistic
Autistic

Sensorium and Cognition

Level of education: good

General knowledge: good
Orientation of T/Pl/Pe/S: good/good/good/good
Working/short/long memory: good
Writing and reading skills: good
Ability to self care: good

Impulse Control When Examined

Self control: Enough
Patient response to examiners question:
Enough

Insight
Impaired

EXAMINATION

PHYSICAL EXAMINATION
Consciousnesss:
Vital

Compos Mentis

sign:

Blood pressure : 150/90 mmHg

Pulse rate
: 86 x/min
Temperature
: 36,5 C
RR
: 24 x/min

REVIEW SYSTEM
a. Head:

Normocephaly, mouth deviation (-)

Anemic conjungtiva (-), icteric sclera (-), pupil isocore

b. Neck: Normal, no rigidity, no palpable lymph

nodes
C. Thorax:

Cor : S1 S2 regular, murmur -, gallop Lung : Vesicular sound +/+, wheezing -/-, ronchi -/-

d. Abdomen:
Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness -, mass -, liver, spleen, and
kidney not palpable
e. Extremity : Warm acral, capillary refill <2, edema (-),
some bruises over elbows and knees

NEUROGICAL EXAMINATION
Cranial nerves examination:
CN
CN
CN
CN
CN
CN
CN
CN
CN
CN

I : in normal finding
II : in normal finding
III,IV,VI : in normal finding
V : in normal finding
VII : in normal finding
VIII : in normal finding
IX : in normal finding
X : in normal finding
XI : in normal finding
XII : in normal finding

Physiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+),
brachioradial (+)
Lower extremities: patella reflex (+), achilles tendon reflex
(+)
Pathological reflex
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski(-), chaddock(-), gordon(-),
oppenheim(-), rossolimo (-)
Motoric examination
Normal movement, good coordination, normal strength

NEUROLOGICAL STATUS

Motorik: Normotonus, good coordination of

movement

Meningeal sign: negative

Physiologic reflex : +/+

Patologic reflex: -/-

SIGNIFICANT FINDINGS

Onset: 1 month
ago

DIFFERENTIAL
DIAGNOSIS
F25.0 Schizo-affective Disorders, Manic type
(Skizoafektif tipe manik)
F30.2 Manic with Psychotic Features
(Manik dengan gejala psikotik)

MULTIAXIAL DIAGNOSIS
Axis I
Axis II

: F25.0 Schizo-affective Disorders, Manic type

: Z03.2 no diagnosis of axis II

Axis III

: Hypertension Grade I

Axis IV

: Divorce, miss her children

Axis V

: GAF on admission 40 31

PROBLEM RELATED TO THE PATIENT

1.
.
.

Problem about patients life (social)

Unable to have any normal interaction
Poor productivity

2 Problem about patients biological state (biology)

There were imbalance of neurotransmitter.
3. Problem about patients mental state (psychology)
Disturbing towards people surrounding her
She did not control her mood. She always happy and
euforia

PLANNING MANAGEMENT

PLANNING MANAGEMENT
Emergency Department
Inj. haloperidol 1 A IM
Inj. diazepam 1 A IV (sedative and muscle
relaxant effect)
Hospitalization risk of damaging herself and
disturbing people surrounding her

RESPONSE PHASE
Target Therapy
50% decrease of symptoms
Maintenance Therapy
Tab. Lithium Carbonat 200 mg o.12.h.
Tab. Haloperidol 5 mg o.12.h.
Tab. Amlodipin 1x10mg

REMISSION PHASE

Target therapy:
- 100% remission of symptoms
Inpatient management:
- Continuing the pharmacotherapy:
Tab. Haloperidol 5 mg o.12.h
Tab. Lithium carbonat 200 mg o.12.h
Tab. Amlodipin 1x10mg
- Improving the patient quality of life:
Teaching patient about her social & environment
(interacting with her family, socializing with her
neighbor or friends, finding a hobby to do on her
spare time)
Outpatient management:
- Pharmacotherapy

RECOVERY PHASE

Continuing the medication, control to

psychiatric

Rehabilitation:

Helping patient to interact normally with her family,

friends, and neighbor
Doing some activities that can keep patient feel
occupied

THANK
YOU