MORNING REPORT

Wednesday Afternoon, February 5th 2014

SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

I. PATIENTS IDENTITY
Autoanamnesis Name Age Gender Address Occupation Marital status Last education Alloanamnesis Name Age Relation : Mrs. R : 39 years old : Female : Tangerang, Banten : unemployed : Married : Elementary school : Mr S : 40 years old : Husband

REASON WHY PATIENT BROUGHT TO HOSPITAL

Havent got a child for 10 years

*Present History
1 weeks ago 6 months ago

Stop Working, the companys bankrupt. Patient become more quite, and often daydreaming. Patient easily got angry if somebody didnt full fill what she needed especially with her husband
Still working as a housewife,
Social life still good, but patient more spending her time in her house utilization of leisure time still good ; patient love to sewing and making clothes Self grooming still good; patient still eat well, and taking a bath daily

Patient become more often get mad. She even ran into her neighbor with carrying a knife. Patient become more quite, and sometimes crying especially when shes praying. Her husband sometimes said that shes talking to her self
Didnt work even as a housewife
Social withdrawal Poor utilization of leisure time Self grooming still good: patient still eat well and taking a bath daily

*Present History
Day of admission

The symptoms worsened. Patient refused to talk Sleep disturbance >>

Didnt want to work even as a housewife, Poor utilization of leisure time : patient spent lots of time with daydreaming Social withdrawal Self grooming still good ; patient still take a bath daily and eat well

Psychiatry history

Never been hospitalized before

General medical history

Hypertension (-) Head injury (-) Convulsion (-) Asthma (-) Allergy (-)

Drugs and alcohol abuse history and smoking history

Drugs consumption (-) Alcohol consumption (-) Cigarette Smoking (-)

* EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric (UNVALID DATA) There were not get important data on patients growth and development such as:

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 her hand(3-6 months) putting everything in her mouth(3-6 months)

Psychosocial (UNVALID DATA) There were not get important data on which age patient

started smiling when seeing anothers 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 (UNVALID DATA) There were not get important data on when patient started babbling. (6-9 months)

Emotion (UNVALID DATA) There were not get important data of patients reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards others and toilet training. Cognitive (UNVALID DATA) There were not get important data on which age the patient can follow objects, recognizing his mother, recognize her family members. There were not get important data on when the patient first copied sounds that were heard, or understanding simple orders.

* INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (UNVALID DATA) not get important data on when patients first time playing traditional games such as hide and seek, glass ball, or if patient ever involved in any kind of sports. Psychosocial (UNVALID DATA) not get important data on patient interaction with her surrounding, not get important data on when patient first entered primary school, how well she play with her new friend on first day school. Communication (UNVALID DATA) not get important data regarding patient ability to make friends at school and how many friends patient have during his school period Emotional (UNVALID DATA) not get important data on patients adaptation under stress, any incidents of bedwetting were not known. Cognitive (UNVALID DATA ) not get important data on patients cognitive.

* LATE CHILDHOOD & TEENAGE

Sexual development signs & activity (UNVALID DATA) No data on when patient experience menarche, hair on armpits and pubis, etc * Psychomotor (UNVALID DATA) No data if patient had any favourite hobbies or games, if patient involved in any kind of sports. * Psychosocial (UNVALID DATA) Patient had never been told family about patients friend. * Emotional (UNVALID DATA) not get important data on patients reaction on playing, scared, showed jealously or competitiveness * Communication (UNVALID DATA) not get important data on how well the relationship between patient with parent and his family.

PHASE

*ADULTHOOD
Educational History
Current Situation
she lived in jakarta with her husband, she had a harmonic life, and had been separated with her family by her choice.

Occupational history
Marital Status

Elementary School

ex tailor. She didnt worked again because her company is bankrupt

Criminal History Social Activity

No

had been married for 10 years but didnt had a child or never been pregnant before

Patient had introvert personality, but still had a good social life with the neighbours.

* Family history

Family history

*Patient is the 7th childs of 8 siblings. *Theres no psychiatry history in the family.

*Psychosexual History
* shes been married
for 10 years, but havent got a child yet and never been pregnant before. Her behavior is appropriate for female.

Genogram

Socio-economic history Economic scale : enough

Validity Alloanamnesis Autoanamnesis : valid : valid

*Progression of disorder
Symptom

August 2013

february 2014

Role function

Mental State (Wednesday, 5th February 2014)

Appearance
A woman, appropriate to her age, completely clothed, self grooming still good.

State of Consciousness
Clear

Speech
Quantity : decreased Quality : decreased

Behaviour
Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Strereotypy Mannerism Automatism
Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

ATTITUDE
Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Active Passive
Infantile Distrust Labile Rigid Passive negativism Catalepsy Cerea flexibility Excitement

Emotion
Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile

Mood
Dysphoric Elevated Euphoria Expansive Irritable Agitation Cant be assessed

Disturbance of perception
Hallucination Auditory (+) Visual (+) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Depersonalisation (-) Illusion

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

Thought progression
Quantity Quality

Logorrhea Blocking Remming Mutisme Talkative

Irrelevan answer Incoherence Flight of idea Coherent Poverty of speech Loosening of association Neologisme Circumtansiality Verbigrasi Perseverasi Sound association Word salad Echolalia

Content of thought

Idea of Reference Over-valued idea Preoccupation Obsession

Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Thought of Echo Thought of

Phobia
Delusion of Persecution Delusion of Reference Delusion of Envious Delusion of Hipochondry Delusion of magic-mystic

Insertion/withdrawal
Thought of Broadcasting Cant be assessed.

Form of Thought

Realistic Non Realistic Dereistic Autistic

Sensorium and Cognition

Level of education school General knowledge Orientation of time/place/people/situation Working/short/long memory Writing and reading skills Visuospatial Abstract thinking Ability to self care

: elementary : cant be assesed : cant be assesed : cant be assesed : not examined : not examined : not examined : good

Impulse control when examined

Self control: enough Patient response to examiners question: poor

Insight

Impaired insight Intelectual Insight True Insight

Internal Status
Conciousnes : compos mentis Vital sign : Blood pressure : 100/70 mmHg Pulse rate : 80 x/mnt Temperature : afebris RR : 20x/mnt

 Head Eyes isocore Neck Thorax: Cor Lung

: normocephali : anemic conjungtiva -/-, icteric sclera -/-, pupil

: normal, no rigidity, no palpable lymph nodes

: S 1,2 Sound and normal : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2,

RESUME
Symptoms Mental Status
Hypoactive Passive Coherent Remming Hallucination (+) auditory & visual Idea of reference Thought of withdrawal

Impairment
Poor utilization of leisure time Didnt want to work even as a housewife Social withdrawal self grooming still good

Easily got angry

Refused to talk Lack of sleep

Differential Diagnose
F20.00 Schizofrenia Paranoid - F25.10 Schizoaffective depressive type - F32.30 Severe Depressive episode with psychotic symptoms.

Multiaxial Diagnose
Axis I Axis II Axis III Axis IV Axis V :F25.1 Schizoaffective depressive type :Introvert :none :Desire for having a child :GAF admission 40-31

*
Hospitalization

purpose

of hospitalization is to decrease the symptoms, so patient can handle herself, and not hurting people around her. Hospital treatment plans should be oriented toward practical issues of quality of life, role function and social relationships. To establish an effective association between patients and community support systems.

*PLANNING MANAGEMENT
Pharmacothisapy

O Emergency therapy O inj. Haloperidol 5 mg im O Inj. Diazepam 5 mg iv

For sedative

effect. O Routine therapy O Trifluoperazine 2 x 5mg po O Amitriptilin 1 x 25mg po

Psycho-education Educate the patient and family after medication: * Explain to patients family about mental disorder. There are many factors cause the symptoms. * Treat the patient according to the familys ability, dont demand the patient more nor less. * Help the patient when he needs it. * Education of the family to encourage communication and understanding.

Ad vitam Ad functionum Ad sanationum

: ad bonam : dubia ad bonam : dubia ad malam

*PROGNOSIS