SUPERVISOR :DR. SABAR P. SIREGAR, SP. KJ

MORNING REPORTJUNE 4TH 2015

PATIENT IDENTITY

Name : Mr. BAge : 23 years oldSex : MaleEthnic : JavaneseAddress : TruntungOccupation : PrivateMarital Status : SingleEducation : Senior High School

ALLOANAMNESIS

Name : Mr. LSex : MaleAge : 52 years oldRelation : Father

REASON PATIENT BROUGHT TO EMERGENCY ROOM

Patient rampage since one week ago

STRESSOR

Unknown ( Because there is not valid data)

PRESENT PSYCHIATRIC HISTORY

Patient has been brought by his father to IGD RSJ Soerojo because he rampage since one week ago. Patient rampage by throwing laptop and bite his father. Patient rampage without any reason. Patient said that he has a power to change the world and also said that he can see “genderuwo” that only he can see and he can communicate to “genderuwo”. Patient said that he has been feeling so happy. Patient difficult to start sleep so he sleep in the middle night but he still feel energic when he woke up.

IMPAIRMENT

• Since the symptom appear, patient can’t work and take a bath

PRESENT PSYCHIATRIC HISTORY

One year ago patient has been brought by his father to IGD RSJ Soerojo with the same symptom and admitted for 18 days. He went to Polyclinic routinely until three months after hospitalization. Five years ago, he has been brought to psychiatrist because he afraid to meet new people.

Drugs, alcohol abuse, and

smoking history

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

General medical history

• Drugs consumption (-)• Alcohol consumption (-)• Cigarette smoking (+)

EARLY CHILDHOOD PHASE EARLY CHILDHOOD PHASE (0-3 YEARS OLD)(0-3 YEARS OLD)

Psychomotoric (NO VALID DATA) • 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 (NO VALID DATA) • 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 (NO VALID DATA) • There were no valid data on when patient started

bubbling (6-9 months)

Emotion (NO VALID DATA) • There were no valid data of patient’s reaction

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

Cognitive (NO VALID DATA) • There were no valid data on which age the

patient can follow objects, recognizing her mother, recognizing her 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) • No valid data on when patient’s first time playing hide

and seek or if patient ever involved in any kind of sports.

Psychosocial (NO VALID DATA)• No valid data on how patient socialized with her

surrounding

Communication (NO VALID DATA) • No valid data regarding patient ability to make

friends at school and how many friends patient have during her school period

Emotional (NO VALID DATA)• No valid data on patient’s adaptation under stress,

any incidents of bedwetting were not known.

Cognitive (NO VALID DATA)• No valid data on patient’s cognitive.

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)• No valid data when patient first experience of

menstruation etc.

Psychomotor (NO VALID DATA) • No valid data if patient had any favourite

hobbies or games, if patient involved in any kind of sports.

Psychosocial• No valid data

Emotional (NO VALID DATA) • No valid data on patient’s reaction on playing, scared,

showed jealously or competitiveness

Communication • No valid data

ADULTHOOD

Educational HistorySenior High School

Occupational history He worked as a shopkeeper until one week ago.

Marital StatusSingle

Criminal HistoryNone

Social Activity No valid data

Current SituationNo valid data

ERIKSON’S 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

There is no psychiatry history in family

Male Female Patient Lives together

GENOGRAM

PROGRESSION OF DISORDER

Symptom

Role function

2010 2014 2015

MENTAL STATE(TUESDAY 26TH MAY 2015)

BEHAVIOUR

•Hypoactive•Hyperactive•Echopraxia•Catatonia•Active negativism•Cataplexy•Streotypy•Mannerism•Automatism•Bizarre•Normoactive

•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

DISTURBANCE OF PERCEPTION

THOUGHT PROGRESSION

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•Autism

SENSORIUM AND COGNITION

Level of education : good General knowledge : good Orientation of time : bad Orientations of place : bad Orientations of peoples : bad Orientations of situation : bad Working/short/long memory : not assessed Writing and reading skills: not assessed Visuospatial : not assessed Abstract thinking : not assessed Ability to self care : good

PHYSICAL STATUS

Consciousnes : compos mentis Vital sign :

◦Blood pressure : 130/70 mmHg◦Pulse rate : 96 x/mnt◦Respiratory Rate : 24 x/mnt◦Temperature : 36,6 °C

Head : normocephali

Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil

isocore , secret (-) , konjungtiva injection (-)

Neck : normal, no rigidity, no palpable lymph nodes

Thorax:

Cor : S 1,2 Sound normal

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

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2”, tremor (-)

Neurological exam : not examined

RESUME Mental StatusBehaviour: Hyperactive

Mood: Euphoria Perception: auditory and visual hallucination Thought progression: logorrhea, incoherence, sound associationContent of thought: delusion of grandiose, delusion of magic mysticForm of thought: non realistic , autistic

Symptom Impairment

SYNDROME

InkoherenceAuditory and visual

hallucinationNonrealistic

SCHIZOPHRENIC SYNDROME

HiperactiveEuphoria

LogorrheaGrandiousity

MANIASYNDROME

DIFFERENTIAL DIAGNOSIS

• F25.0 Schizoaffective Disorder Manic Type• F30.2 Manic with Psychotic Symptoms

MULTIAXIAL DIAGNOSIS

Axis I : F25.0 Schizoaffective Disorder Manic Type

Axis II : Z03.2 No diagnosisAxis III : No diagnosisAxis IV : He didn’t like mathematics subject in

schoolAxis V : GAF on admission 20-11

PROBLEM RELATED TO THE PATIENT

1. Psychology ProblemThe patient has introvert personality . Patient had

problems in school, he didn’t like mathematics subject in school.2. Social Problem

- 3. Problem about patient’s biological state

There was an abnormality increase in dopamine and serotonin in mesolimbic .

PLANNING MANAGEMENT

Inpatient (hospitalization)Purpose of hospitalization is to decrease the symptoms :

Rampage

RESPONSE PHASE

Target therapy : 50% decrease of symptoms

Emergency department Antipsychotics :

Haloperidol 5 mg IM

Antianxiety : Diazepam for sedative effects and muscle relaxant (IV)

REMISSION PHASE

Target therapy : 100% remission of symptoms

Inpatient management1. Continue the pharmacotherapy:

Haloperidol 2 x 5 mg OralLithium carbonate 2 x 200 mg Oral

2. Improving the patient quality of life

Outpatient management1. Pharmacotherapy2. Psychosocial therapy

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1 year.

THANK YOU