SUPERVISOR dr. Sabar P. Siregar, Sp.KJ

MORNING REPORT

Sunday morning, 2nd March 2014

Name : Mr. F Age : 22 years old Gender : Male Address : Purbalingga Occupation:Unemployed Marriage status : Single Last education : SPM (finished)

Name : Mr. S Age : 53 years old Relation : Father

IDENTITY

GUARDIANPATIENT

THE REASON PATIENT WAS BROUGHT TO THE HOSPITAL

Day-dreamingand Lost of interest (Do not want to

do anything)

STRESSOR

UNCLEAR

PRESENT HISTORY

Patient was on high school in Purwokerto, while one day his parents know patient was drinking alcohol. Since that patient has lost his mood, has willing to do nothing, and mostly only sit quietly at home and daydreaming.

Patient also known to take a lot of medicines, such as “pil koplo”, and he took any medicine he sees, such as bodrex, etc.Patient was addicted to the drugs, that he was selling things to get the drugs

2009

Hospitalized in mental institute Purwokerto for 10 days and he was allowed to

go home.

- He was selling things to get drugs.- He didn’t take care of himself- He don’t want to work.

Patient commited suicide by hanging himself.

He didn’t want to work He didn’t take care of himself Poor utilization of leisure time

2010

Hospitalized in Banyumas for 10 days and allowed

to go home.

Patient’s parents did not see any improvement, so they took their son to a hospital for drug addiction

He didn’t want to work He didn’t take care of himself Poor utilization of leisure time

2010

Hospitalized for around 7 days

• He got angry when he asked for motorcycle and his mom did not give to him• He don’t have any purpose of life• He don’t want to do anything but sitting down and daydreaming• Can not sleep at night

He didn’t want workHe didn’t take care of himselfPoor utilization of leisure time

Day of admissionPatient was taking herbal

medicine. Parents claim that patient shows improvement. • Patient still locked himself

inside his house often• Not willing to do anything and

only daydreaming• His sleeping time is disturbed

He didn’t want to workHe didn’t take care of himselfPoor utilization of leisure time

2011-2014

There was no psychiatric history.

Psychiatric history

• Head injury (+)• Hypertension (-)• Convulsion (-)• Asthma (-)• Allergy (-)• History of admission (-)

General medical history

• Drugs consumption (+)

• Alcohol consumption (+)

• Cigarette Smoking (+)

Drugs and alcohol abuse

history and smoking history

PERSONAL HISTORY

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Patient’s family can not recall any impairment on growth and development, beside a history of febrile seizure on age 4 months old, 5 times. Other milestone can not be assessed properly.

Psychomotoric (mother forgot)Parents can not recall the times 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 (mother forgot) 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 (mother forgot) • There were forgot on when patient started saying words 1 year like ‘mom’ or

‘dad’. (1 year old)

Emotion (mother forgot) • There were forgot of patient’s reaction when playing, frightened by

strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive (mother forgot) • There were forgot on which age the patient can follow objects, recognizing

her mother, recognize her family members.• There were forgot on when the patient first copied sounds that were

heard, or understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)Psychomotor (mother forgot)

forgot on when patient’s first time playing hide and seek or if patient ever involved in any kind of sports.

Psychosocial (mother forgot)forgot about patient’s social relation.

Communication (mother forgot) forgot regarding patient ability to make friends at school and how many

friends patient have during his school period

Emotional (mother forgot)forgot on patient’s adaptation under stress, any incidents of bedwetting

were not known.

Cognitive (mother forgot)forgot on patient’s cognitive.

LATE CHILDHOOD & TEENAGE PHASESexual development signs & activity (mother forgot)

Patient first experience of wet dreaming, etc.Psychomotor

Patient had hobbies such as fixing mechanical things at workshop, and he liked to ride motorcycle and speed on the road.

Psychosocial Parents claimed that he had some friends that he often protected if

his parents said that his friends are not a good friends.Emotional (mother forgot)

forgot on patient’s reaction on playing, scared, showed jealously or competitiveness

Communication Patient can communicate well.

Other : - Patient was trying to drink alcohol the first time, and was vomiting

a lot. (14 yrs old)- Patient had accident while riding motorbike. His head hit the

ground, but he did not lose consciousness. He was then taken to a health service but then allowed to go home, without any further examination. (17yrs old)

ADULTHOOD Educational History

SPM. Finished. Patient is considered smart, academic achievement good.

Occupational history -

Marital StatusSingle.

Criminal HistoryNo

Social Relation Good relationship, he has many

friends.

Current SituationHe lived with his father and his mother.

ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT

Stage Basic Conflict Important EventsInfancy(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

Patient is the first child with three female siblings.

Psychiatry history in the family (-).

FAMILY HISTORY

GENOGRAM

P

• Patient • Suffers from mental illness• Female• Male

P

Patient knows that he is male, his behavior is appropriate for male, he’s attracted to woman.

Psychosexual history

Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : valid• Autoanamnesis : not valid

PROGRESSION OF DISORDER

Symptom

Role function

20142009 2013

Mental State(Sunday, 2 March 2014)

Appearance • A man, appropriate to his age, completely

clothedState of Consciousness• Clear

Speech• Quantity : decreased• Quality : decreased

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

• Cooperative• 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• Can’t 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 (-)

Thought progressionQuantity

• Logorrhea• Blocking• Remming• Mutism• Talk active

Quality

• Coherence• Irrelevant answer• Incoherence• Flight of idea• Poverty of speech• Confabulation• Loosening of association• Neologisme• Circumtansiality• Tangential • Verbigrasi • Perseverasi • 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• Delusion of Suspicious• Thought of Echo• Thought of Insertion /

withdrawal• Thought of Broadcasting• Idea of suicide

Form of thought•Realistic•Non Realistic•Dereistic•Autistic

Sensorium and Cognition Level of education : Good General knowledge : Can’t be assessed Orientation of time : Can’t be assessed Orientations of place : Can’t be assessed Orientations of peoples : Can’t be assessed Orientations of situation : Can’t be assessed Working/short/long memory: Can’t be assessed Writing and reading skills : Can’t be assessed Visuospatial : Can’t be assessed Abstract thinking : Can’t be assessed Ability to self care : Low

Impulse control when examined•Self control: Enough•Patient response to

examiners question: Poor

Insight •Impaired insight•Intellectual Insight•True Insight

Internal StatusConsciousnes : compos mentisVital sign :

◦Blood pressure : 110/90 mmHg◦Pulse rate : 80 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

RESUMEDAY OF ADMISSION

SymptomsMental Status• Bizzare

• Non-Cooperative• Dyphoric• Blunted• Halucination visual &

auditorik• Remming• Inchoherence• Non Realistic• Impaired insight• Delusion of Suspicious• Thought of Insertion/

withdrawel

Impairment

He didn’t want workHe didn’t take care of himself

• He got angry when he asked for motorcycle and his mom did not buy• He don’t have any purpose of life• He don’t want to do anything but sitting down & daydreaming• Can not sleep at night•History of tentament suicide

Differential DiagnosisF20.0 Paranoid SchizophreniaF20.1 Hebephrenic SchizophreniaF25.0 Schizoaffective Manic Type

Multiaxial Diagnosis

Axis I : F 19.75– Gangguan Mental dan Prilaku akibat Penggunaan Zat Multipel dan Penggunaan Zat Psikoaktif Lainnya, Gangguan psikotik residual/onset lambat

Axis II : R46.8 delayed diagnosis of axis IIAxis III : -Axis IV : Fight with the family Axis V : GAF admission 20-11

PLANNING MANAGEMENT

Inpatient (hospitalization)Purpose of hospitalization is to decrease

the symptoms, so patient can handle himself.

Improve social and occupational skills

Response Remission Recovery

RESPONSE PHASE

Emergency departmentAntipsychotics : Inj. Haloperidol 5mg i.m.Anxiolytics (Sedative effect)

: Inj. Diazepam 10mg i.v.

Re-assess patientAdditional examination : screening of NAPZA

•Target therapy : 50% decrease of symptom (Irritable, not having purpose of life, daydreaming, sleeping problem)

REMISSION PHASEInpatient managementPharmacotherapyPsychosocial and occupational rehabilitationRehabilitation to drug and addictive compound.Education to family

Outpatient managementPharmacotherapyPsychosocial therapy

Target therapy : 100% remission of symptom within 4-9 months (Irritable, not having purpose of life, daydreaming, sleeping problem)

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1 year.(Irritable, not having purpose of life, daydreaming, sleeping problem)

Pharmacotherapy

Psychotherapy

Occupational and social rehabilitation

Family education

Outpatient management

Thank you...