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Morning Report

Thursday October 3rd , 2014

Patients Identity
1.
2.
3.
4.
5.
6.
7.
8.

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: AS
: 24 years old
: Male
: Magelang
: Unemployed
: Single
: Javanese
: Junior High School

Identity
Alloanamnesis was conducted to :
I

II

Mr. I

Mr. H

Age

57 years old

33 years old

Sex

Male

Male

Magelang

Magelang

Teacher

Entrepreneur

Educational
status

SPG

Undergraduate

Relationship

Uncle in Law

Brother in Law

Duration of
relationship

7 years

7 years

Strength of
relationship

Fair

Fair

Name

Address
Job

Psychiatric History
Morning Report
Thursday October 3rd , 2014

Chief Complaint
Agitation
Rampage
Destroyed household

History of Present Illness


4 years before patients admission
Patient was back from his job in Kalimantan with unknown
reason. When he was back, he locked himself in his room,
was irritable, and easily got angry. He destroyed his househ
olds, because he heard voices that asked him to do that.
One day, he burnt his parents house. Her brother in law an
d uncle in law tried to stop him, and when they broke into t
he burning house, they found him sitting desperately and s
aid that he wanted to kill himself.
After that incident, they brought him to RSJS and he got hi
mself admitted. After one month, he got better and got dis
charged.

History of Present Illness


6 months before patients admission
Patient didnt take medicine routinely because always forgot to take t
he medicine. Because of that, the symptoms arose again. He heard vo
ices that asked him to burn his medicine and he couldnt resist that. S
o he burnt the medicine and didnt take the medicine.
After that, he locked himself in his room because he was lazy. He ate
and drank when he was asked to. He destroyed the households and c
ouldnt get enough sleep. Because of that, he looked tired.
In contrast, when he went out from house, he wandered around and
spent all of his money. His motorcycle also was sold so he could got m
oney to be spent by him. No one knew where the money was spent.
Because of that, he was taken to RSJS Magelang and got admitted. B
ut when he was in RSJS Magelang, he ran away from RSJS because he
said he had problem with some girl.

History of Present Illness


5 months before patients admission
Patient was brought back to RSJS and got admitted by her fa
mily. After he was better, he was discharged from the hospit
al.
1 day before patients admission
He didnt take his medicine. The symptom arose again. He w
as easily agitated, got rampage, difficult to sleep and destroy
ed things. He said that he got stressed because the disease di
dnt get better and he thought about ending his life. He said
that he saw shamans that kept whispering him to do someth
ing, and if he didnt do what that shamans asked, they threat
ened him. After that, he was brought to RSJS Magelang.

History of Past Illness


Psychiatric illness
o There is no history of psychiatric illness in this patien
t
General medical illness
o There is no history of high fever, seizure, head trau
ma, or any other serious illness which needs hospital
ization
Substance abuse
o History of alcohol abuse, but no clear data about ho
w long and how often he got drank.
o Patient smokes cigarette 1-2 packs/day

Depiction of Illness
Symptoms
2010

Role
Function

2014

2011

Family History
There is history of psychiatric illness in his
mothers aunt.
There is no history of high fever, seizure,
head trauma, or any other serious illness
which needs hospitalization

Genogram

History of Personal Life


Prenatal and perinatal
o There was no valid data in patients prenatal
and perinatal aspect, such as :
Patients mothers age and condition whe
n she was pregnant
Patients mothers delivery history and pati
ents perinatal condition.
Patients immunization status

History of Personal Life

Early childhood phase (0-3 years old)


o Psychomotor

There was no valid data in patients psychomotor aspect (such as tilting the b
ody, supine to prone, sitting, standing, walking, smiling, holding her own ha
nd, scoop up object, holding pencil and pilling up two objects)
Psychosocial
There was no valid data in patients psychosocial aspect (such as replying to s
mile, smiling when seeing interesting object, playing cilukba, knowing her fa
mily members and pointing what she wanted without crying)
Communication
There was no valid data in patients communication aspect (such as bubblin
g, cooing, making sounds without meaning, telling 2-3 syllables without me
aning and calling mama/papa)
Emotion
There no valid data in patients emotion aspect (such as when patient playin
g, frightened by strangers, starting to show jealousy or competitiveness tow
ards other, and toilet training)
Patient didnt pee or defecate in her pants when she was two years old
Cognitive
There was no valid data in patients cognitive aspect (such as copying sounds
that she heard for the first time and understanding simple orders)

History of Personal Life

Intermediate childhood phase (3-11 years old)


o Psychomotor
o

o
o

No valid data on when patients first time playing hide and seek or if pati
ent ever involved in any kind of sports.
Psychosocial
Patient was an introvert boy. He seldom played with his peer.
Patients parents always spoiled him. They never got angry to him. It mad
e him dared to resist his parents.
Communication
Patient didnt have any trouble to communicate with others (such as intr
oducing herself and talking with others).
Emotion
Patient was a shy boy and didnt use to showing his emotion.
Cognitive
Patient started his school in elementary school when he was 7 years old.
He was not really a smart boy and had failed a grade..

History of Personal Life

Late childhood and teenage phase (11-18 years old)


o Psychomotor
o

No valid data if patient had any favorite hobbies or games, if patient involve
d in any kind of sports.
Psychosocial
Patient was an introvert boy. He seldom played with his peer.
Patients parents always spoiled him. They never got angry to him. It made
him dared to resist his parents.
Communication
Patient didnt have any trouble to communicate with others (such as introd
ucing herself and talking with others)
Emotion
Patient was a shy boy. He was quite and often day dreaming. Patient could
nt resist stressors and tended to get stressed out.
Cognitive
After graduating from elementary school, patient continued to study to jun
ior high school. Patient had a poor achievement in academic.
After graduating from junior high school, patient continued to senior high
school until 2nd grade. He dropped out because he lack of interest in study.
He once skipped school because he was unable to solve his homework.

History of Personal Life

Adulthood phase (18 years old-now)


o Educational
Patient dropped out in 2nd grade of high school because he lack of interest in
study.

o Occupational
Patient had work in Yogyakarta for 2 days as a labor. Patient stopped working
for unclear reason.
Then he went to Kalimantan, worked in a plantation for one month. After th
at, patient stopped working. He went home because he said that he want to
get married.

o Marital status
Patient has not got married yet.

o Criminal
He has no criminal history

o Social activity
Patient was an introvert, he seldom played with his peer. He is quite and ofte
n day dreaming.

o Current situation
Patient lives with her mother, father, and brothers. His brother currently enter
s the collage.

History of Personal Life


Psychosexual history and sexual development
o Patient had wet dream when he was in class 1-2 junior hig
h school
o Patient realizes that he is a male, and interested in female.
His attitude is appropriate as a male.
o Patient was taught to be a male and played with his male p
eers.
o Patient never had a girlfriend.
Socioeconomic history
o Patient doesnt have any job now
o Economic scale : low
Degree of validity : valid

Eriksons stages of psychosocial development


Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

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

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)

Maturity
(65- death)

Examination
Morning Report
Thursday October 3rd , 2014

Physical Examination
Morning Report
Thursday October 3rd , 2014

General physical examinat


ion
o General appearance :
Good nutritional status

o Vital sign

BP : 110/70 mmHg
HR : 94x/m
to : afebris
RR: 20x/m

General physical examinat


ion
Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes


Thorax

Cor : S1 S2 regular, murmur -, gallop

Lung

: vesicular sound +/+, wheezing -/-, ronchi-/-

Abdomen

flat, abdominal wall//chest wall, normal peristaltic, tympany sound, tenderness -, ma


ss -, liver, spleen and kidney not papable

Extremity

: Warm acral, capp refill <2, edema (-)

Neurological examination
Level of Consciousness :
o compos mentis, E4V5M6 (15)

General Appearance :
o Body posture : normal
o Abnormal movement : o Walking style : normal

Neurological examination
Cranial nerves examination:
o
o
o
o
o
o
o
o
o
o

CN I
CN II
CN III,IV,VI
CN V
CN VII
CN VIII
CN IX
CN X
CN XI
CN XII

: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding

Neurological examination
Motoric
o Upper extremities: tonus (+), trophy : eutrophic, power of movement
: shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve functio
n : 5, ulnar nerve function : 5, median nerve function : 5
o Lower extremities: tonus (+), trophy : eutrophic, power of movement
: hip joint : 5, knee joint : 5, ankle joint : 5

Sensorium
o DCML system : proprioception, fine touch : no abnormalities
o AL system : vibration, temperature, crude touch, pain : no abnormalit
ies

Neurological examination
Physiological reflex
o Upper extremities: biceps reflex (+), triceps reflex (+), brachioradial (+)
o Lower extremities: patella reflex (+), achilles tendon reflex (+)

Pathological reflex
o Upper extremities: Hoffman (-), Tromner (-)
o Lower extremities: babinski (-), chaddok (-),gordon (-),oppenheim (-), rossoli
mo (-), clonus -/-

Meningeal sign
o Neck stiffness (-), brudzinski neck sign (-), brudzinski contralateral leg sign (-),
kernig sign (-)

Cerebellum function
o Adhyadokokinesia (-), romberg test (-), finger to nose test (no abnormalities),
tip to toe walk (no abnormalities)

Mental State Examination


Morning Report
Thursday October 3rd, 2014

General Appearance
A man, age 24 years old, appropri
ate to his age, fair grooming

Consciousness
Clear

Orientation

Time
: good
People : good
Place
: good
Situation : good

Behavior
o
o
o
o
o
o
o
o
o
o

Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare

o Command automatism

o
o
o
o
o
o
o
o
o
o
o

Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

Attitude
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Emotion
Affect

Mood

Dysphoric
Depressed
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation

Inappropriate
Broad
Restrictive
Blunted
Flat
Labile

Disturbance in Perception
Hallucination

Auditory (+)
Visual (+)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)

Illusion

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

Progression of Thought
Quantity

Logorrhea
Blocking
Remming
Mutism
Talkative

Quality

Irrelevant answer
Coprolalia
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
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac

Delusion of Magic-mystic

Idea of suicidal

Delusion of Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Idea of Suspicion
Thought of Echo
Thought of Insertion &
withdrawal
Thought of Broadcasting

Form of Thought

Non Realistic
Dereistic
Autism
Cannot be evaluated

Cognitive Function

Level of education
: finished junior high school
General knowledge
: good
Working/short/long memory : good
Writing and reading skills : good
Visuospatial
: good
Abstract thinking
: good
Ability to self care
: fair

Impulse Control When Examined


Self control: good
Patient response to examiners question: good

Insight
Impaired insight
Intellectual Insight
True Insight

Resume
Morning Report
Thursday October 3rd, 2014

Resume
Symptom:
o
o
o
o
o
o
o
o
o
o
o

he locked himself in his room


Irritable
easily got angry
destroyed his households
burnt his parents house.
sitting desperately and said that he wanted to kill himself.
couldnt get enough sleep
wandered around
got rampage
saw shamans that kept whispering him to do something
if he didnt do what that shamans asked, they threatened him

Mental Status:
o
o
o
o
o
o

Behavior : hypoactive
Mood : depressed
Affect : blunted
Perception : auditory and visual hallucination
Content of thought : idea of suicidal, idea of suspicion, delusion of control, thought insertion and withdrawal, thought of broadcasting
Form of thought : non realistic

Impairment:
o Patient cant socialize with others
o Patient has fair grooming
o Patient cant work

Symptom and Sign Grouping (Syndrome)


Symptoms and Signs

Syndrome

Irritable
Easily got angry
Destroyed household
Wandered around
Got rampage
Visual and auditory hallucination

Psychotic Syndrome

Blunted
Idea of suicidal, idea of suspicion,
delusion of control, thought insertion
and withdrawal, thought of
broadcasting
Non realistic form of thought
Couldnt get enough sleep
Depressed mood
Sitting desperately

Depression Syndrome

Diagnosis
Morning Report
Friday September 26th, 2014

Differential Diagnosis
F20.0 Schizophrenia paranoid
F20.2 Schizophrenia catatonic
F25.1 Depressive type schizoaffective disorder

Multiaxial Diagnosis

Axis I : F20.0 schizophrenia paranoid


Axis II : R46.8 delayed axis II diagnosis
Axis III : no axis III diagnosis
Axis IV : no work, cant socialize with others
Axis V : GAF admission 20-11

Management
Morning Report
Friday September 26th, 2014

Patients problems
Biological problem
o Positive symptoms because of increase amount of dopamine in the post sinap
s neuron

Psychological problems
o Patient couldnt resist stressors and tended to get stressed out

Social problem
o He has no work
o He cant socialize well with others

Management Planning
Hospitalization
o Patient was hospitalized because :
the idea of suicidal
troubling others by agitated, easily get angry and destroying household
fair grooming
the appearance of the positive symptom (delusion, hallucination, etc)

After that, were planning for response, remission and


recovery phase for this patient

Response Phase
o Target therapy :
50% decrease of symptoms

o Emergency department
Diazepam Inj 5 mg IV (for its sedative and muscle relaxation effe
ct)
Haloperidol Inj 5 mg IM (to reduce positive symptoms)

o Maintenance
ECT (to reduce the positive symptoms, especially when patient tri
ed to suicide)
Haloperidol Tab 5 mg PO 2x1 (to reduce positive symptoms)

o Re-assess patient

Remission Phase

Target therapy :
o 100% remission of symptom

Inpatient management
o Risperidone Tab 2mg PO 1x1 (to reduce the positive sympto
m and decrease the possibilities of side effect)
o Improving the patient quality of life :
Teach patient about her social & environment (interact with her f
amily, socialize with her neighbor or friends, find a hobby to do
on her spare time)

Outpatient management
o Continuation of pharmacotherapy
o Psychosocial therapy

Recovery Phase
Continue the medication, control to psychi
atrist
Rehabilitation :
- Consult to psycholog to help patient to fi
nd a hobby
- Help patient to interact normally with her
family and neighbor

Family Education
Explain to the family that anyone could have mental disorders
Mental disorders are caused by multifactorial factor, not by ge
netic
Mental disorders mostly are affected by chemical imbalance in
brain
Mental disorders can be controlled by medicines, so it is impor
tant to take the medicines routinely
Treat patient like you treat any other people
Help patient if he should be helped
Dont push patient to understand the family, but his family tha
t has to understand him
Dont be too emotional to patient

Thank You!
Sayounara!
Thursday October 3rd , 2014