MORNING REPORTSupervisor : dr. Sabar P. Siregar, Sp.KJ

Wednesday night shift,Wednesday night shift, 1717hh September 2014 September 2014

Patient Identity

•Name : Mr S•Sex : Male•Age : 45 years old•Address : Magelang•Occupation : Unemployed•Marital State : Divorced•Education : Junior High School

RELATIVES IDENTITY

• Name : Mrs. Nn• Sex : Female• Age : 42 years old• Relation : Younger sister

Reason patient was brought to emergency room

Patient had symptoms of uncontrolled anger, rampage, talking and laughing for unknown

reasons since a week ago

Stressor

His mother didn’t give money

Present History

After dischargefrom RSJS 2 months ago with similar symptoms, he

didn’t go to RSJS for therapy. He also didn’t take the medicines

regularly.

After dischargefrom RSJS 2 months ago with similar symptoms, he

didn’t go to RSJS for therapy. He also didn’t take the medicines

regularly.

• He had decreased appetite, talking and laughing non-sense. He was still able to

socialize and do daily activities.

• He had decreased appetite, talking and laughing non-sense. He was still able to

socialize and do daily activities.

2 months ago

Present History

Uncontrolled anger,rampage, more talking and laughing

for unknown reasons.Patient was said to have stop taking

drugs.

Uncontrolled anger,rampage, more talking and laughing

for unknown reasons.Patient was said to have stop taking

drugs.

• He was not able to do daily activities and had difficulty in sleep. He didn’t

socialize with others and still had decreased appetite

• He was not able to do daily activities and had difficulty in sleep. He didn’t

socialize with others and still had decreased appetite

A week ago

PSYCHIATRIC HISTORY

He had been hospitalized for 3 times since 4 years ago

Day of Admission17th September 2014

Patient was brought because of:• Uncontrolled anger• Rampage•More talking and laughing for unknown reasons•Patient was said to have stop taking drugs.

Brought to hospital by the sister

• He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased

appetite

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)EARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (No Valid Data)- there were no valid data on which age patient

• first time lifting the head (3-6 months)• rolling over (3-6 months)• Sitting (6-9 months)• Crawling (6-9 months)• Standing (6-9 months)• walking-running (9-12 months)• holding objects in his hand(3-6 months)• putting everything in his mouth(3-6 months)

Psychosocial (No Valid Data)- there were no valid data on which age 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)

Psychomotoric (No Valid Data)- there were no valid data on which age patient

• first time lifting the head (3-6 months)• rolling over (3-6 months)• Sitting (6-9 months)• Crawling (6-9 months)• Standing (6-9 months)• walking-running (9-12 months)• holding objects in his hand(3-6 months)• putting everything in his mouth(3-6 months)

Psychosocial (No Valid Data)- there were no valid data on which age 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) - there were no valid data on when patient started bubbling. (6-9 months)

Emotion (NO VALID DATA)- there were no valid data 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) - there were no valid data on which age the patient can follow objects,

recognizing his mother, recognize his family members.- there were no valid data on when the patient first copied sounds that

were heard, or understanding simple orders.

Communication (NO VALID DATA) - there were no valid data on when patient started bubbling. (6-9 months)

Emotion (NO VALID DATA)- there were no valid data 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) - there were no valid data on which age the patient can follow objects,

recognizing his mother, recognize his family members.- there were no valid data on when the patient first copied sounds that

were heard, or understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (NO VALID DATA) No valid data on when patient’s first time playing hide and seek or if

patient ever involved in any kind of sports.

Psychosocial No valid data regarding patient psychosocial.

CommunicationNo valid data regarding patient ability to make friends at school and

how many friends patient have during his school period.

Emotional (NO VALID DATA)No valid data on patient’s emotional.

CognitivePatient was one class backward at 2nd standard of elementary school.

Psychomotor (NO VALID DATA) No valid data on when patient’s first time playing hide and seek or if

patient ever involved in any kind of sports.

Psychosocial No valid data regarding patient psychosocial.

CommunicationNo valid data regarding patient ability to make friends at school and

how many friends patient have during his school period.

Emotional (NO VALID DATA)No valid data on patient’s emotional.

CognitivePatient was one class backward at 2nd standard of elementary school.

LATE CHILDHOOD & TEENAGE PHASELATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity No valid data on patient’s sexual development

PsychomotorNo data if patient had any favourite hobbies or games, if patient involved in

any kind of sports.

Psychosocial No valid data regarding patient psychosocial.

Emotional historyNo valid data on patient’s emotional history.

CommunicationNo valid data regarding patient ability to make friends at school and how

many friends patient have during his school period.

Sexual development signs & activity No valid data on patient’s sexual development

PsychomotorNo data if patient had any favourite hobbies or games, if patient involved in

any kind of sports.

Psychosocial No valid data regarding patient psychosocial.

Emotional historyNo valid data on patient’s emotional history.

CommunicationNo valid data regarding patient ability to make friends at school and how

many friends patient have during his school period.

ADULTHOOD

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 1st child of 2 siblings.•There is no psychiatry disorder in family history.

Genogram

Female

Male

Dead

Patient Live in one house

Divorced

PSYCHOSEXUAL HISTORY

Patient realizes that he is male, and has interests to female. His attitude is appropriate as a male.

Progression of Disorder

Symptom

Role Function

July, 2014 NowAugust, 20132010

Mental State 17th September 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• Indifferent• Apathy• Tension• Dependent• Passive

•Infantile•Distrust•Labile•Rigid•Passive negativism•Catalepsy•Cerea flexibility•Excited

Emotion

Disturbance of Perception

Depersonalization (-) Derealization (-)

Thought Progression

Content of Thought

• Idea of Reference

• Idea of Guilt

• Preoccupation

• Obsession

• 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

•Non Realistic•Dereistic•Autistic•Cannot be evaluated

Sensorium and Cognition

Level of education : Junior high school General knowledge : not assessed Orientation of time : Good Orientations of place : Good Orientations of people : Good Orientations of situation : Good Working/short/long memory: Not assessed Writing and reading skills: Not assessed Visuospatial : Not accessed Abstract thinking : Not accessed Ability to self care : Poor

Physical State

Consciousnes : compos mentisVital sign :◦Blood pressure : 110/70 mmHg◦Pulse rate : 86 x/mnt◦Temperature : 36.7◦RR : 18 x/mnt

Consciousnes : compos mentisVital sign :◦Blood pressure : 110/70 mmHg◦Pulse rate : 86 x/mnt◦Temperature : 36.7◦RR : 18 x/mnt

Review System Head : Normocephali, mouth deviation (-)

Eyes : Anemic (-), icteric (-),

Neck : No rigidity, no palpable lymph nodes

Thorax :

Cor : S1-S2 reguler, murmur (-)

Lung : Vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic sound,

Extremity : Warm ,capillary refill tine <2”, edema (-)

Neurological exam : Not examined

RESUME

• A man, 45 years old, appropriate according to his age, completely clothed, poor self care

• Reason to be brought to hospital were Uncontrolled anger, rampage, more talking and laughing for unknown reasons. Patient was said to have stop taking drugs.

• He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite

Mental Status Impairment

-Mood: dysphoric

- Perception: auditoric hallucination (+)

-Content of Thought : idea of guilt, delusion of persecution

- Form of thought: non-realistic

- Impaired insight

• Uncontrolled anger

• Rampage • More talking

and laughing for unknown reasons

He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite

Differential Diagnosis

F20.0 Paranoid Schizophrenia

F25.2 Schizoaffective mixed-state type

Multiaxial Diagnosis

Axis I : F20.0 Paranoid Schizophrenia Z91.1 Discontinuation of

medicationAxis II : Z03.2 No diagnosisAxis III : No diagnosisAxis IV : Problems with the primary support

group (family)Axis V : GAF on admission 30-21

PLANNING MANAGEMENTPLANNING MANAGEMENTPLANNING MANAGEMENTPLANNING MANAGEMENT

Inpatient (hospitalization)• Patients had Uncontrolled anger, rampage,

more talking and laughing for unknown reasons. He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite since 1 week ago.

RESPONSE PHASERESPONSE PHASERESPONSE PHASERESPONSE PHASE

Target therapy : 50% decrease of symptoms

Emergency departmentHaloperidol 5mg i.mDiazepam 10 mg i.v (sedative and muscle relaxant effects)MaintanceHaloperidol 2x5mg

Re-assess patient

REMISSION PHASEREMISSION PHASEREMISSION PHASEREMISSION PHASE

Target therapy : 100% remission of symptom

Inpatient managementContinue pharmacotherapy: Haloperidol 2x5mgImproving the patient quality of life : Teach patient about his social & environment(interact with his relatives, socialize with his neighbors, get a new job, find a hobby to do his spare time)

Outpatient management1.Pharmacotherapy : Haloperidol 2x5mg2.Psychosocial therapy

RECOVERY PHASERECOVERY PHASERECOVERY PHASERECOVERY 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 his family and neighbor

Family education :-Explain to his family about patient’s mental disorder and his treatment.-Educate his family to support not to exile the patient.-Ask his family to monitor patient’s progress and make sure the patient takes medicine as prescribed.

THANKYOU