MORNING REPORT

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

Saturday
29
th
March
2014
IDENTITY
Name : Mrs. R
Age : 27 years old
Gender : Female
Address : Kebumen
Occupation : Unemployed
Marriage status : Married
Last education : Junior High School
Name : Mr. S
Age : 31 years old
Relation : Husband


GUARDIAN PATIENT
The reason patient was brought to
the hospital :
Restless

STRESSOR
conflict with
mother in
law
PRESENT HISTORY
Patient was brought by her
family because she was
restless without any reason.
She also did not want to talk
to the other.
2013
(August)
Since then
she
admitted to
the RSJS
Magelang.

- She did not want to work
- She did not socialize with neighbours
- She did not took goodcare of herself
- She did not take care her child

She readmitted to hospital because:
Restless
Did not want to eat
Did not want to speak
Sometimes laughing and talking to
herself
Prefer to be alone
March 2014
Since then
she
admitted to
the RSJS
Magelang.

- She did not want to work
- She did not socialize with neighbours
- She did not took goodcare of herself
- She did not take care her child

Restless
Didnt want to speak
Didnt want to eat
Prefer to be alone
Day of admission
Brought to
RSJS ER
by her
husband.

- She did not want to eat, sleep and
work
- She did not socialize with neighbours
- She did not took goodcare of herself
- She did not take care her child

Since 2009, patient was admitted
to the RSJS Magelang for five
times because of paranoid
schizophrenia and
undifferentiated schizophrenia
Psychiatric
history
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
History of admission (-)
General
medical
history
Drugs consumption (-)

Alcohol consumption (-)

Cigarette Smoking (-)
Drugs, alcohol
abuse, and
smoking history
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Patients family can not recall any impairment on growth and development.
Other milestone can not be assessed properly.

Psychomotoric (no valid data)
There is no valid data when patient:
First time lifting the head (3-6 months), rolling over (3-6 months)
Sitting (7-8 months)
Crawling (6-9 months)
Standing (6-9 months)
Walking-running (16 months)
Holding objects in her hand (3-6 months)
Putting everything in her mouth (3-6 months)

Psychosocial (no valid data)
Parents can not recall the times when 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)
They were forgot on when patient started saying words 1 year like
mom or dad. (1 year old)

Emotion (no valid data)
They were forgot of patients reaction when playing, frightened by
strangers, when starting to show jealousy or competitiveness
towards other and toilet training.

Cognitive (no valid data)
They were forgot on which age the patient can follow objects,
recognizing her mother, recognize her family members.
They were forgot on when the patient first copied sounds that were
heard, or understanding simple orders.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Psychomotor (no valid data)
forgot on when patients first time playing hide and seek or if patient ever
involved in any kind of sports.
Psychosocial (no valid data)
forgot about patients social relation.
Communication (no valid data)
forgot regarding patient ability to make friends at school and how many
friends patient have during his school period
Emotional (no valid data)
forgot on patients adaptation under stress, any incidents of bedwetting were
not known.
Cognitive (no valid data)
forgot on patients cognitive.
LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity (no valid data)
Patient first experience of menarche, etc.

Psychomotor (no valid data)
Patient had hobby

Psychosocial(no valid data)
Parents claimed that she had some friends.

Emotional (no valid data)
There is no valid data on patients reaction on playing, scared,
showed jealously or competitiveness

Communication (no valid data)
Patient can communicate well.
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 3rd child with six siblings
Psychiatry history in the family (+)
Genogram
Mental disorder Patient
Patient knows that she is female, her behavior is
appropriate for female, shes attracted to man.


Psychosexual history
Socio-economic history
Economic scale : low
Validity
Alloanamnesis : valid
Autoanamnesis : not valid
Progression of disorder
Symptom
Role function
2009 2014 2010
2011
2012
2013
Mental State
(Saturday, 29 March 2014)
Appearance
A female, appropriate to her age, completely
clothed.
State of Consciousness
Cloudy
Speech
Quantity : decreased
Quality : decreased
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
Non-
cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excitement
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile
Disturbance of perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
CAN NOT BE ASSESSED
Thought progression
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
Incoherence
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of
association
Quality Quantity
Logorrhea
Blocking
Remming
Mutism
Talkative
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
Delusion of Suspicious
Thought of Echo
Thought of Insertion /
withdrawal
Thought of Broadcasting
Idea of suicide
CAN NOT BE ASSESSED
Form of thought
Realistic
Non Realistic
Dereistic
Autistic
Sensorium and Cognition
Level of education : can not be assessed
General knowledge : can not be assessed
Orientation of time : can not be assessed
Orientations of place : can not be assessed
Orientations of peoples : can not be assessed
Orientations of situation : can not be assessed
Working/short/long memory: can not be assessed
Writing and reading skills : can not be assessed
Visuospatial : can not be assessed
Abstract thinking : can not be assessed
Ability to self care : bad

Impulse control when
examined
Self control: Enough
Patient response to
examiners question:
Bad
Insight
Impaired insight
Intellectual Insight
True Insight
Internal Status
Consciousnes : compos mentis
Vital sign :
Blood pressure : 130/90 mmHg
Pulse rate : 98 x/mnt
Temperature : Afebris
RR : 20 x/mnt, regular

Head : normocephali
Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax:
Cor : S 1,2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, tremor (-)
Neurological exam : not examined
Symptoms
-Restless
-Did not want to
speak
-Did not want to
eat
-Prefer to be
alone
Mental Status
Behavior: TIC,
psychomotor
agitation.
Mutism
Poverty of
speech
Impaired insight
Impairment
- She did not want
to eat, sleep and
work
- She did not
socialize with
neighbours
- She did not took
goodcare of
herself
- She did not take
care her child
Differential Diagnosis
F20.5 Residual Schizophrenia
F25.1 Schizoaffective Depressive Type
F32.3 Severe Depression with Psychotic
Sign

Multiaxial Diagnosis
Axis I : F32.3 Severe Depression with Psychotic Sign
Axis II : R 46.8 Delayed of Axis II diagnosis
Axis III : There is no diagnosis
Axis IV : Stressor was conflict with mother in law
Axis V : GAF on admission 30-21

Problem related to the patient
1. Problem about patients family
She had conflict with her mother in law

2. Problem abour social economy
Her economic condition was low

3. Problem about patients biological state
In Schizophrenia there is abnormal balancing of the neurotransmitter
(decreased of serotonin) limbic system which has the contribution for
the negative symptoms : Restless, did not want to speak, did not want
to eat, prefer to be alone. We need pharmacotherapy for re-balancing
the neurotransmitter
PLANNING MANAGEMENT
Inpatient (hospitalization)
Purpose of hospitalization is to decrease the
symptoms :
Restless
Did not want to speak
Did not want to eat
Prefer to be alone
Response Remission Recovery
RESPONSE PHASE
Target therapy : 50% decrease of symptom
Restless
Did not want to speak
Did not want to eat
Prefer to be alone

Emergency department
Antipsychotic: Typical (Haloperidol inj 5mg im)

Maintenance
Antidepressant: SSRI (Fluoxetine 2 x 20 mg po)
Antipsychotic: Atypical (Risperidone 2 x 2 mg po)

Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom within 4-9 months
Restless
Did not want to speak
Did not want to eat
Prefer to be alone
Inpatient management
1. 1. Continue the pharmacotherapy:
Antidepressant: SSRI (Fluoxetine 2 x 20 mg po)
Antipsychotic: Atypical (Risperidone 2 x 2 mg po)
1. 2. Improving the patient quality of life :
teach patient to care about herself (took a bath, toothbrushing)
Teach patient about her social & environment
( moping, clean the floor, washing the dishes)
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
got & apply her skill
Family education
Thank you