MORNING REPORT Monday 2 nd JuneMay 2014 PATIENT IDENTITY Name : Mrs. SN Sex : female Age : 33 years old Address : Kebumen Occupation : Labor Marital State : Married General education : primary school
RELATIVES IDENTITY Name : Mr. S Sex : Male Age : 58 years old Relation : father REASON PATIENT WAS BROUGHT TO EMERGENCY ROOM Patient was angry without any reason and damaging anythings. STRESSOR Unclear PRESENT HISTORY Angry without reason, gelisah, keluyuran Hospitalize in RSJ 2010 she didnt go to work she couldnt utilize his leisure time she didnt socialize with neighbor She poor grooming she was hospitalized I : for 1 months in 2010 II : for 1 months in 2012 III : for 1 months in 2013 IV : for 1 months in 2014 DAY OF ADMISSION 02 June 2014
Brought to hospital by his father
she cant do his daily activity. she couldnt socialize with friends she cant go to work Poor grooming Patient brought with the complaints of: Angry without reason unable to sleep Attact his husband talking to himself
PSYCHIATRIC HISTORY No psychiatric history General medical history Head injury (-) Hypertension (-) 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 - There were no valid 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 - 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 - There were no valid data on when patient started bubbling. (6-9 months)
Emotion - There were no valid data of patients reaction when playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.
Cognitive - 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) Psychomotor No valid data on when patients first time playing hide and seek or if patient ever involved in any kind of sports. Psychosocial No valid data regarding patient psychosocial. Communication No valid data regarding patient ability to make friends at school and how many friends patient have during his school period Emotional No valid data on patients emotional. Cognitive No valid data on patients cognitive. LATE CHILDHOOD & TEENAGE PHASE Sexual development signs & activity No data on when patient first experience of menarcher
Psychomotor No 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 No valid data on patients emotional.
Communication No valid data regarding patient ability to make friends at school and how many friends patient have during his high school period ADULTHOOD Educational History finished primary school, he is average student in the class
Occupational history In 2008, the patient worked in a factory, then he was dismissed due to bankruptcy 2013-now, the patient worked in a factory Marital Status they married in 2005 in 2008, he divorced his wife. They have 1 child
Criminal History No Criminal history.
Social Activity Before he was sick, he was friendly and had many friends
Current Situation He lives with his parents and his brother ERIKSONS 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 4 th child of 6 siblings
There is no psychiatry history in the family Genogram MALE FEMALE Patient PSYCHOSEXUAL HISTORY . Patient realizes that she is a female, and interest to a male. Her attitude is appropriate as a female Socio-economic history Economic scale : low Validity Alloanamnesis: valid Autoanamnesis: valid Progression of Disorder Symptom Role Function 2008 2009 2010 2011 27/05/2014 2013 2012 Appearance A male, appropriate to his age, completely clothed State of Consciousness Cloudy Speech Quantity : Decreased Quality : Decreased MENTAL STATE 27 TH 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 Cant 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 Hipochondry Delusion of magic-mystic Delusion of grandiose Delusion of Control Delusion of Influence Delusion of Passivity Delusion of Perception Thought of Echo Thought of Insertion & withdrawal Thought of Broadcasting Form of Thought Non Realistic Dereistic Autism Cannot be evaluated
Sensorium and Cognition Level of education : primary school General knowledge : Cant be accessed Orientation of time : Cant be accessed Orientations of place : Cant be accessed Orientations of people : Good Orientations of situation : Cant be accessed Working/short/long memory : Cant be accessed Writing and reading skills : Cant be accessed Visuospatial : Cant be accessed Abstract thinking : Cant be accessed Ability to self care : Cant be accessed Impulse control when examined
Self control: enough Patient response to examiners question: bad Insight
1. -Seizure 2. -unable to sleep 3. -talking to himself 4. -angry without any reason 5. -disturbing other people He cant do his daily activity. he couldnt socialize with friends He cant go to work Poor grooming Decrease appetite Male 31 years old, appropiate to his age, completely clothed Differential Diagnosis F06.1 Katatonik Organic Disorder F20.4 Skizophrenia Catatonic Multiaxial Diagnosis Axis I : F06.1 Catatonik Organic Disorder Axis II : Z03.2 No Diagnose Axis III : Hypertension grade II, Seizure Axis IV : unclear Axis V : GAF admission 40-31 PROBLEM RELATED TO THE PATIENT
1. Problem about patients life in 2008, Patients were laid off by the company because to bankrupt. Patients had been divorced by his wife. he never met with the child and his wife.
2. Problem about patients biological state In Schizophrenic patient, there is abnormal balancing of the neurotransmitter (increasing of dopamine) which has the contribution for the positive symptoms : have hallucination and delusion. We need pharmacotherapy to rebalance the neurotransmitter.
PLANNING MANAGEMENT Inpatient (hospitalization) To reduce 50% the symptoms : 1. Seizure 2. unable to sleep 3. talking to himself 4. angry without any reason 5. disturbing other people 6. Poor grooming 7. Decrease appetite 8. hipertension
Inpatient management 1. Continue the pharmacotherapy: maintenance Haloperidol 2x5mg & captopril Tab 2x12,5 mg, 2. Improving the patient quality of life : Teach patient about his social & environment (interact with his family, socialize with his neighbor or friends, find a hobby to do on his spare time)
Outpatient management 1. Pharmacotherapy 2. Psychosocial therapy RECOVERY 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 her family, his friends and neighbor - Family education such as tell his family about patient condition and how much familly support affect the success of therapy