SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT

Friday, 14th March 2014

IDENTITY

• Name : Mr. W• Age : 39 years old• Gender: Male• Address: Cilacap• Occupation:Unemployed • Marriage status :divorced • Last education : Elementary school

• Name : Mr. R• Age : 44 years old• Relation : brother in law

GUARDIANPATIENT

The reason patient was brought to the hospital

• Easily got angry• Laughed by himself• Couldn’t sleep

STRESSOR

Suspect :-His father passed away (±3 years ago)-Got divorced from his wife (±2 years ago)

PRESENT HISTORY

After his father passed away(because of unknown illness) , he became:• often day dreamed• laughed by himself•Locked himself on his room•Couldn’t sleep ( slept at 3 am and wake up at 6 am)

2011

- He didn’t want to work- Poor uti;ization of leisure time- He still could take care of himself

Suddenly he received divorced letter from his wife. Then his wife left him and took their daughter along with her.

After that he became more : -Often found out day-dreaming-Easily got angry-Hard to sleep- Often wandering around

He didn’t want to work Poor utilization of leisure time Took care of himself

2012

The family brought him to

Puskesmas.But his family

said that he didnt show any improvementThey didn’t come back

again to Puskesmas

his brother in law said that the patient’s condition gets worsened, he became :

-Easily got angry-Easily attack his family -Still couldn’t manage his sleeping time

-More often wandering around

He didn’t work Poor utilization of leisure time Social withdrawal Poor grooming

2013

Brought to RSJS ER

by her brother in law after being

referred by Puskesmas

2014

The family ignored the patient’s condition until

someone told them to bring the patient to RSJ to get

medication.

The patient’s family was educated and convinced that

patient can gets better.

There was no psychiatric history.

Psychiatric history

• Head injury (+)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)• History of admission (-)

General medical history

• Drugs consumption (-)

• Alcohol consumption (-)

• Cigarette Smoking (+) 1 pack /day

Drugs and alcohol abuse

history and smoking history

Personal History

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

• Patient’s family can not recall any impairment on growth and development. Other milestone can not be assessed properly.

Psychomotoric (no valid data)Brother in law can not recall the times 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)Brother in law 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)

• 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.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)• 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.

LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity (no valid data)

Patient first experience of wet dreaming, etc.Psychomotor (no valid data)

The guardian didnt know wether patient had hobbies or not. Psychosocial (no valid data)– The guardian didn’t know wether patient had friends and close to

them or not. Emotional (no valid data)

forgot on patient’s reaction on playing, scared, showed jealously or competitiveness

Communication (no valid data) Patient is believed that he can communicate well.

Erikson’s stages of psychosocial developmentStage 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 last child of four siblings (4th child)• Father passed away since 3 years ago.• He lives with her mother, but when patient was

angry, mother leave the patient.• Psychiatry history in the family (-).

Genogram

Patient

• Patient knows that he is male, his behavior is appropriate for male, he’s attracted to woman.

• Patient got married once (on 2000), and divorced 2 years ago (2012). He has a daughter. Now the daughter lives with the mother. The patient hasn’t seen her eversince.

Psychosexual history

Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : valid• Autoanamnesis: not valid

Progression of disorder

Symptom

Role function

2011 2014

Mental State(Thursday. 6 March 2014)

Appearance • A man, appropriate to his age, completely clothed

State of Consciousness• Cloudy

Speech• Quantity : increased• Quality : increased

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

• Dysphoric• Euthymic• Elevated• Euphoria• Expansive• Irritable• Agitation• Can’t be assesed

Affect

• Appropriate• 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 progressionQuantity

• Logorrhea• Blocking• Remming• Mutism• Talk active

Quality

• Coherence• 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 : Good General knowledge : Good Orientation of time : Bad Orientations of place : Good Orientations of peoples : 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

Internal StatusConsciousnes : compos mentisVital sign :

◦Blood pressure : 130/80 mmHg◦Pulse rate : 122 x/mnt◦Temperature : Afebris◦RR : 20 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

Mental Status

• Mood: elevated.• Affect : inappropiate• Talk active

• Loosening of association

• Circumtansiality

• Auditory and visual hallucination

• Dellusion suspicious• Impaired insight

Impairment

He didn’t want to workPoor utilization of leisure timePoor groomingSocial Withdrawal

•He wandered around•Easily gets angry, attacked his sister•Talked & laughed by himself•Hard to start to sleep and manage it.

Problem related to the patient• 1. Problem about patient’s family• Father passed away 3 yearsago• Got divorced and was being separated from his daughter since 2 years ago

• 2. Problem about patients personalityunknown

• 3. Problem about patient’s biological state• There is abnormal balancing of the neurotransmitter, increasing of dopamine &

serotonin which is have the contribution for the positive symptoms : wandered around, have delusion, ilusion, halucination.

• We need pharmacotherapy for re-balancing the neurotransmitter

• 4. Problem about patient’s economy state• Patient is considered poor, and didn’t want to work so he didn’t get money.

Differential DiagnosisF20.0 Paranoid SchizophreniaF25.0 Schizoaffective Manic Type

Multiaxial Diagnosis

Axis I :F25.0 Schizoaffective manic typeAxis II : R46.8 delayed diagnosis of axis IIAxis III : Head trauma?Axis IV : Father passed away

Got divorced, separated from daughterAxis V : GAF admission 30-21

PLANNING MANAGEMENT

Inpatient (hospitalization)Purpose of hospitalization is to decrease the

symptoms :Wandered waround, Angry without any reason, Sometimes hit peopleHallucination

Response Remission Recovery

RESPONSE PHASE

Target therapy : 50% decrease of symptom (Wandered waround, angry without any reason,sometimes

hit people,hallucination) Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m.because the patient has positive symptom(Wandered waround, angry without any reason,sometimes hit people,hallucination)

MaintanceHaloperidol 2x5mg po

Re-assess patient

REMISSION PHASETarget therapy : 100% remission of symptom within 4-9 months (Wandered around, angry without any reason,sometimes hit people,hallucination)

Inpatient management1. Continue the pharmacotherapy: Haloperidol 2x5mg po2. Improving the patient quality of life : –teach patient to care about himself (took a bath, toothbrushing)Teach patient about his social & environment( moping, clean the floor, washing the dishes)–Outpatient management1. Pharmacotherapy2. Psychosocial therapy

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1 year.(Wandered waround, angry without any reason,sometimes hit people,hallucination)

Continue the medication, control to psychiatric

Rehabilitation : help patient to got & apply his skill

Family education

Thank you...