SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT
Friday, May 9th 2014
Patient Identity
Autoanamnesis
Name :
Sex :
Age : years old
Address :
Occupation :
Marital State :
Alloanamnesis
Name :
Sex :
Relation :



Reason patient was brought to
emergency room
Patient refuse to take his medicine and
showing weird behavior
Stressor
Meeting his wife and children
who didnt live in the same house
Past History
Patient has history of hospitalization at 2003, 2009,
2 times at 2010, 2013, and March 2014.
He usually brought to hospital because of going
mad, refusing to take his medicine, wandering
around, and disturbing his neighbours.
He started showing symptoms around 2003
because he was fired from his job in Jakarta. And
started living separately from his wife and children.
His smoking habit became more frequent when
hes about to relapse.
Day of Admission




9th May 2014
Patient brought with the
complaints of:
Didnt take his medicine
Refused going to hospital for
routine control
Giving his wares to other people
without any reason

Brought to hospital
by his mother


He worked as a merchant
Poor utilization of leisure time
He couldnt socialize with friends

The patient didnt take any medicine
for 4 days
General
medical history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
Drugs and alcohol
abuse history and
smoking history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (+) - frequency
increased when symptoms worsened
ADULTHOOD
Educational History
He finished junior high
school

Occupational history
He started to work in
Jakarta when he was 15 yr
old. His mother didnt
know anything about his
occupation.

Marital Status
Married, but not living in
the same house

Criminal History
No
Social Activity
Before he was sick, he was
a friendly guy and had
many friends

Current Situation
He lives with his parents,
he has no friends. And he
works as a merchant
FAMILY HISTORY
Patient is the 2nd child of 4 siblings

Psychiatry history in the family his younger
sister also has same symptom

GENOGRA
M
Pria Wanita Pasien
Meninggal
PSYCHOSEXUAL HISTORY
Patient realizes that he is a male, and interested in
female. His attitude is appropriate as a male.
Socio-economic history
Economic scale : low
Validity
Alloanamnesis: valid
Autoanamnesis: valid
Progression of Disorder
Symptom
Role Function
2003 2013 2014 2009 2010 2010
Appearance
A male, appropriate to his age, completely clothed,
nicely groomed
State of Consciousness
Clear
Speech
Quantity : Increased
Quality : Decreased
Mental State
May 9
th
2014
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
Excited
Stable
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Appropriate
Inappropriate
Broad
Restrictive
Blunted
Flat
Stable
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
Talkative
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
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of Magic-mystic
Delusion of Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicion
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 : finished junior high
school
General knowledge : good
Orientation of time : good
Orientations of place : good
Orientations of people : good
Orientations of situation : good
Working/short/long memory: good
Writing and reading skills : good
Visuospatial : cant be accessed
Abstract thinking : cant be accessed
Ability to self care : good


Self control: enough
Patient response to
examiners question:
good

Impaired insight
Intellectual Insight
True Insight
Impulse control
when examined
Insight
Physical State
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/90 mmHg
Pulse rate : 100 x/min
Temperature : Afebrile
RR : 22 x/min
Review System
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, motoric strength
Neurological exam : not examined
Mental Status Impairment

- Attitude: Cooperative,
hyperactive, bizzare
- Mood: Euphoric
- Affect: Appropriate, stabil
- Perception: Gustatory illusion
- Thought Progression: Talkative,
coherrent
- Form of Thought: Non-realistic,
fantasy, delusion of suspicion
and religion
-Patients response to question:
good
- Impaired insight


Didnt take his
medicine
Refused going to
hospital for
routine control
Giving his wares
to other people
without any
reason
He didnt work
Poor utilization of
leisure time
He couldnt
socialize with
neighbor
Symptoms
Patient is a male, 43 years old, nicely groomed, has a history of admittion in
psychiatric ward. Symptoms elevation started since 4 days ago.
Differential Diagnosis
F20.04 Paranoid Schizophrenia incomplete
remission
F20.5 Residual Schizophrenia
Multiaxial Diagnosis
Axis I : F20.00 Continous Paranoid
Schizophrenia
Z91.1 Noncompliance of medication
Axis II : Z03.2 none
Axis III : no diagnosis
Axis IV : meeting wife and children who didnt
live together
Axis V : GAF admission 40-31
RESPONSE PHASE
Target therapy : 50% decrease of symptoms

Emergency department
Haloperidol inj 5mg im
Diazepam inj 10mg iv

Maintenance
Risperidone 2x2mg per day

Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom

Inpatient management
Continue the pharmacotherapy: maintenance Risperidone 2x2mg
Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor, continue his job, find a
hobby to spend 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 his
family and neighbor
- Family education