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MORNING REPORTSaturday, 22thMarch
2014
SUPERVISOR dr. Sabar P. Siregar,
Sp.KJ
Identity
Name : Mr. UY Age : 28 years old Gender : Male Address : Petanahan,
Kebumen Occupation : - Marriage status : Divorced Last education : JHS
Name : Mr. B Age : 46 years old Relation : Elder Brother
GUARDIANPATIENT
Talking-singing-shouting non stop too much
The reason patient was brought to the hospital
STRESSOR
? ?
?
PAST HISTORYThe first time admitted to RSJS was because of being violent, getting angry, and destroying things. He was then diagnosed F20.3. he was admitted to RSJS for about only 1 week, and he ran away from RS.
2013
- Can work again but very rarely- He utilized his leisure time hanging out
with his friend, and they give him alcohol and drugs again
- He took goodcare of himself about so-so
• 2 months before he was brought, the patient admitted again to RSJS for the very same reason. After 1 month treated, he ran away again from RSJS.
• 2 weeks before he was brought, he started talking-singing-shouting non stop so the others was feeling disturbed. He also couldnt sleep and often wandered around randomly.
He cant do his usual work Poor utilization of leisure time hanging out
with friends, drinking and taking drugs He could take care of himself
March 2014PRESENT HISTORY
• Patient kept talking-shouting-singing non stop and uttering random words.•And he was then brought to RSJS Magelang
Day of admission
Brought to RSJS ER
by his elder
brother
The patient was admitted to the RSJS Magelang for TWO times
(2013, and January 2014) because of undifferentiated
schizophrenia
Psychiatric history
• Head injury (-)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)• History of admission (-)
General medical history
•Drugs consumption (+)
• Alcohol consumption (+)
• Cigarette Smoking (+)
Drugs, alcohol
abuse, and smoking history
Patient’s family can not recall any impairment on growth and development. Other milestone can not be assessed properly.
Psychomotoric (no valid data)There is no valid data 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) Parents 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)
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
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.
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.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Sexual development signs & activity (no valid data)Patient first’s wet dreaming, etc.
Psychomotor (no valid data) There is no valid data on patient’s hobbies
Psychosocial Parents claimed that he had some friends.
Emotional (no valid data) There is no valid data on patient’s reaction on playing, scared,
showed jealously or competitivenessCommunication
Patient can communicate well.
LATE CHILDHOOD & TEENAGE PHASE
Stage Basic Conflict Important EventsInfancy(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
Erikson’s stages of psychosocial development
Family history
Patient is the last child with four siblinga Psychiatry history in the family (-)
Genogram
Patient Psychiatric Disorder
Patient knows that he is male, his behavior is appropriate for female, he is attracted to woman.
He has been married for ?? years and has 2 children
Psychosexual history
Socio-economic history
• Economic scale : average
Validity
• Alloanamnesis : valid• Autoanamnesis : valid
Progression of disorder
Symptom
Role function
2004 2014
Mental State(Thursday 20th March 2014)
Appearance • A man, appropriate to his age, completely
clothedState of Consciousness• Clear
Speech• Quantity : increased• Quality : decreased
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• Talkative
Quality
• 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 : Can’t be assessed General knowledge : Can’t be assessed Orientation of time : Good Orientations of place : Can’t be assessed Orientations of peoples : Good Orientations of situation : Can’t be assessed Working/short/long memory : Can’t be assessed Writing and reading skills : Can’t be assessed Visuospatial : Can’t be assessed Abstract thinking : Can’t be assessed Ability to self care: Good
Impulse control when examined• Self control: Enough
Insight • Impaired insight• Intellectual Insight• True Insight
Internal StatusConsciousnes : compos mentisVital sign :
◦Blood pressure : 130/80 mmHg◦Pulse rate : 120 x/mnt◦Temperature : Afebris◦RR : 24 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
Talking-shouting-singing randomly non-stopWandering aroung randomly
Mental Status• Behavior : not cooperative
• Affect: inappropriate, labile
• Mood: euphoric
• Orientation: difficult to assess
• Form of thought: autistic, non realistic
• Progression of thought: logorrhea, word salad, neologisme, sound association
• Insight: impaired
Impairment
Disturbance of role function
Differential Diagnosis
F20.3 Undifferentiated SchizophreniaF25.0 Schizoaffective Manic Type
Multiaxial DiagnosisAxis I : F31.4 Bipolar Disorder with Depressive
Episode and Psycotic SignsAxis II : no diagnosisAxis III : no diagnosisAxis IV :Axis V : GAF on admission
1. Problem about patient’s family
2. Problem about social economyhis economic condition is average
3. Problem about patient’s biological stateIn Schizoaffective patient, there is abnormal balancing of the neurotransmitter (increasing of dopamine) which has the contribution for the positive symptoms : have hallucination. We need pharmacotherapy for re-balancing the neurotransmitter
Problem related to the patient
Inpatient (hospitalization)
Purpose of hospitalization is to decrease the symptoms : talking non stop Wandering around
PLANNING MANAGEMENT
Response Remission
Recovery
Target therapy : 50% decrease of symptom (wandered around, hallucination)
Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m., Inj. Diazepam 10mg im. (wandered around, hallucination)
MaintenanceQuetiapine 1x200 mg (morning)Clozapine 1x50 mg (night)
Suggest : Re-assess patientSupportive therapy from family
RESPONSE PHASE
Target therapy : 100% remission of symptom within 4-9 months (wandered around, hallucination)
Inpatient management1. Continue the pharmacotherapy: Quetiapine 1x200 mg and Clozapin 1x50 mg po2. Improving the patient quality of life :
Teach patient about his social & environment(take care of children, moping, clean the floor,
washing the dishes, etc)
Outpatient management1. Pharmacotherapy2. Psychosocial therapy
REMISSION PHASE
Target therapy : 100% remission of symptom within 1 year.(wandered around, hallucination)
RECOVERY PHASEContinue the medication, control to psychiatric
Rehabilitation : help patient to got & apply his skill
Family education
Thank you~ :*