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morning report jiwa
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SUPERVISOR dr. Sabar P. Siregar, Sp.KJ
MORNING REPORTSaturday, May 17th 2014
Patient IdentityAutoanamnesis• Name : Mr. B• Sex : Male• Age : 24 years old• Address : Purworedjo• Occupation : Unemployed• Marital State : Single
Alloanamnesis• Name : Mrs. S• Sex :Female• Age : 54 years old• Relation : Mother
Reason patient was brought to emergency room
Patient was talking to himself, angry without any reason, unable to sleep
Stressor
Unclear
Day of Admission17th May 2014
Patient brought with the complaints of:
• talking to himself• angry without any
reason• unable to sleep
Brought to hospital by his
mother
He didn’t workPoor utilization of leisure time
He couldn’t socialize with friends
The patient didn’t take any medicine
Past HistoryJune 2013
Patient brought to RSJS by his family because he was mad without any reason. He also disturbed his neighbour. He was hospitalized.
He didn’t go to workHe can’t utilize his leisure timeHe didn’t socialize with neighbor
Patient was given risperidone and clozapine and got bettter after care.
Patient discontinued medication after being discharged from hospital
because he lives far from hospital (not acessible)
PSYCHIATRIC HISTORY
Hospitalized in RSJS for 20 days in June 2013
General
medical
history
•Head injury (-)•Hypertension (-)•Convulsion (-)•Asthma (-)•Allergy (-)
Drugs and
alcohol abuse
history and
smoking
history
•Drugs consumption (-) •Alcohol consumption (-)•Cigarette Smoking (+)
Erikson’s 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 3rd child of 5 siblings
• Psychiatry history in the family (-)
GENOGRAM
MALE FEMALE Patient
PSYCHOSEXUAL HISTORY
Patient realizes that he is a male, and interests to a female. His attitude is
appropriate as a male.
Socio-economic history
• Economic scale : low
Validity
• Alloanamnesis: valid• Autoanamnesis: valid
Progression of Disorder
Symptom
Role Function
June 2013
May 2014
Appearance
• A male, appropriate to his age, completely clothed
State of Consciousness
• Clear
Speech
• Quantity : Decreased• Quality : Decreased
Mental State 7th 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• 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 (-)
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 Hypochondriac
• Delusion of magic-mystic
• Delusion of grandiose
• Delusion of Control
• Delusion of Influence
• Delusion of Passivity
• Delusion of Perception
• Delusion of Suspicion
• 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 : finished junior high school
General knowledge : can’t be accessed Orientation of time : bad Orientations of place : bad Orientations of people : bad Orientations of situation : bad Working/short/long memory: can’t be accessed Writing and reading skills : can’t be accessed Visuospatial : can’t be accessed Abstract thinking : can’t be accessed Ability to self care : can’t be accessed
Self control: enoughPatient response to examiners question:
bad
Impaired insightIntellectual Insight
True Insight
Impulse control when examined
Insight
Physical State
Consciousnes : compos mentisVital sign :
◦Blood pressure : 130/80 mmHg◦Pulse rate : 73 x/mnt◦Temperature : afebrile◦Respiration rate : 22 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”, motoric strength
Neurological exam : not examined
RESUMEDay of admission
Mental Status Impairment
- Hypoactive- Attitude: Tension, labile- Mood: Euthymic- Affect: Restrictive- Perception: none- Thought Progression: Blocking,
poverty of speech- Form of Thought: Realistic- Patient’s response to question:
bad- Intelectual insight
• Got angry easily
• Cutting neighbor’s trees
• Wandering around home holding an axe
• He didn’t work• Poor utilization of
leisure time• He couldn’t
socialize with neighbor
Symptoms
Patient is a male, 53 years old, poor grooming, has a history of adminition in psychiatric ward. Symptoms elevation started since half month ago.
Differential Diagnosis
F20.3 Undifferentiated SchizophreniaF20.5 Residual Schizophrenia
Multiaxial Diagnosis
Axis I : F20.3 Undifferentiated Schizophrenia Z91.1 Noncompliance of medication
Axis II : Z03.2 noneAxis III : noneAxis IV : Social problem (disturbing neighbor)Axis V : GAF admission 20-11
PLANNING MANAGEMENT
Inpatient (hospitalization)To reduce 50% the symptoms : • Got angry easily• Wandering around home holding an axe• Cutting down neighbor’s trees without
any reason
Response Remission Recovery
RESPONSE PHASETarget therapy : 50% decrease of symptoms
Emergency departmentHaloperidol inj 5 mgDiazepam tab 5 mg
MaintenanceHaloperidol 2x5mg
Re-assess patient
REMISSION PHASETarget therapy : 100% remission of symptom
Inpatient management› Continue the pharmacotherapy: maintenance Haloperidol
2x5mg› 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 spend his spare time)
Outpatient management1. Pharmacotherapy2. Psychosocial therapy
RECOVERY PHASE
Target therapy : 100% remission of symptom within 1 year.
- Continue medication, control to psychiatric- Rehabilitation : help patient to find a hobby,
help patient to interact normally with his family and neighbor
- Family education
Thank You…