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MORNI

NG
REPORT
Saturday 4
th

October 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

PATIENTS IDENTITY
Name
: Mr. H
Sex
: Male
Age
: 82 years old
Address
: Banjarnegara
Occupation
: Unemployed
Marital State
: Widower

RELATIVEs
IDENTITY
Name
Age
Address
Occupation
Education
Relation with
patient
Duration of
Relationship
Strength

I
Mr. M
40 y.o
Wonosobo
Employer (in
Wonosobo)
Senior High School
Son
40 years
Fair

The Reason Patient was Brought to


Emergency Room

Patient has been :


Talk by himself
Throwing household
Getting angry
Poor grooming

STRESSOR

His wife died, then he lived alone and


abandoned by his children.

Present History of ilness


In 2011, he had similar symptoms such as talk by
himself, and getting angry, but not as severe as now, so
he was brought by her son to the primary health care to
get some medication and he gets well

2 weeks ago he began to talk by himself, getting angry


especially to his grand children, throwing household,
wandering around

DAY OF ADMISSION
4th

October 2014

2 weeks ago
he began to
talk by
himself,
getting angry
especially to
his grand
children,
throwing
household,
wandering
around

Brought to
hospital by his
son, because of:
Talk by himself
Throwing
household
Getting angry
Poor grooming

PSYCHIAT
RIC
HISTORY

No psychiatric history

General Medical
History

Head injury (-)


Hypertension (-)
Convulsion (-)
TB (+)
Allergy (-)

Drugs & Alcohol


Abuse &
Smoking History

Drugs consumption (-)


Alcohol consumption (-)
Cigarette Smoking (+)

Progression of Disorder
Symptom 2011

2014

Sympto
ms
Role of
function

Prenatal & Perinatal


Prenatal

Prenatal care has given by midwife

Perinatal

No valid data

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)


His son doesnt know his childhood and the
patient doesnt remember anything
Psychomotor

No valid data in psychomotor aspect (such as tilting the body, supine to


prone, sitting, standing, smiling, holding her own hand, scoop up
object, holding pencil and pilling up two objects)

Psychosocial

No valid data in psychosocial aspect (such as replying to smile, smiling


when seeing interesting object, knowing her family members and
pointing what she wanted without crying)

Communication

No valid data in communication aspect (such as bubbling, cooing,


making sounds without meaning, telling 2-3 syllables without meaning
and calling mama/papa)

Emotion

No valid data In emotion aspect (such as when patient playing,


frightened by strangers, starting to show jealousy or competitiveness
towards other, and toilet training)

Cognitive

No valid data in cognitive aspect (such as copying sounds that she


heard for the first time and understanding simple orders)

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)


Psychomotor

No valid data in psychomotor aspect

Psychosocial

No valid data in psychosocial aspect

Communication

No valid data in communication aspect

Emotional

No valid data in emotional aspect

Cognitive

No valid data in cognitive aspect

LATE CHILHOOD & TEENAGE PHASE


Sexual development signs & activity
No valid data on patients sexual development
Psychomotor (NO VALID DATA)
No valid data on patients favourite hobbies or games, if
patient involved in any kind of sport
Psychosocial
He is sociable person. He doesn't have any problem with his
family
Emotional (NO VALID DATA)
No valid data on patients emotional When she was a teenager
Communication
Sociable person, and have many friend

ADULTHOOD
Educational History
He graduated from elementary school, and didnt
continue because of economic problem
Occupational history
He was a farmer and doing well in his job
Marital Status
Widower, his wife dead 5 years ago

Criminal History
No criminal history
Social Activity
He is a sociable person and have many friends
Current Situation
He lives alone, even his children lives near his house

FAMILY HISTORY
The patient is the 3rd child and has 3
siblings
No Psychiatry history in the family

GENOGRAM

PSYCHOSEXUAL
HISTORY
Patient realizes that he is a
male
Has interests to female
His attitude is appropriate as
a male
SOCIO-ECONOMIC HISTORY
Economic scale : low
Patient doesnt have any job now
VALIDITY
Alloanamnesis
: valid
Autoanamnesis : valid

MENTAL STATE

Mental State

30h September 2014

Appearance
A male, appropriate to his age, completely
clothed, fair appearance
State of Consciousness
Clear
Speech
Quantity : normal
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

ATTITUDE

Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive
negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

EMOTION
AFFECT

MOOD

Dysphoric
Elevated
Euphoria
Expansive
Irritable
Agitation
Euthymic

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile
Wide

DISTURBANCE OF
PERCEPTION
H A L LU C I N AT I O N
Visual (+) : he is
seeing mbah
guru
Auditory (+) : he
listens to mbah
guru advising
him, and he
heard his friends
that was already
dead speaking
Depersonalization
(-)
to him

I L LU S I O N

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

Derealization (-)

THOUGHT PROGRESSION
QUANTITY

Logorrhea
Blocking
Remming
Mutism
Talk active

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

Delusion of grandiose

Idea of Reference

Idea of Guilt

Preoccupation

Obsession

Delusion of reference
Delusion of Influence
Delusion of Passivity
Delusion of Perception

Phobia

Delusion of Persecution

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion

Delusion of Hipochondry Thought of withdrawal

Delusion of magic-mystic
Thought of

Delusion of Suspicious

FORM OF THOUGHT
Realistic
Dereistic
Non Realistic
Autism
Cannot be evaluated

SENSORIUM AND
COGNITION

Level of education
: Elementary school
General knowledge
: Poor
Orientation of time
: Poor
Orientations of place
: Good
Orientations of people
: Good
Orientations of situation : Good
Working/short/long memory : poor in
short memory and calculation
Writing and reading skills : not assessed
Visuospatial
: not assessed
Abstract thinking
: not assessed
Ability to self care
: Good

Impulse Control
when Examined
Self control: Good
Patient response to
examiners
question: Good

Insight
Impaired
Insight
Intellectual
Insight
True Insight

PHYSICAL STATE
Consciousness : compos mentis
Vital sign
Blood pressure
: 90/50 mmHg, adult cuff,
left handed
Pulse rate
: 92 bpm, regular
Temperature
: Afebrile
RR
: 18 x/mnt, thoracoabdominal

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, no murmur heard

Lung : vesicular sound, wheezing -/-,


ronchi-/ Abdomen

: Pain (-) , normal peristaltic,

RESUME
A male, appropriate to her age, completely
clothed, fair appearance
Reason to be brought to hospital are:

Talk by himself
Throwing household
Getting angry
Poor grooming

RESUME

Symptom
s

DAY OF ADMISSION
-

Mental
Affect: apropiate, wide
Mood:Status
euthymic

Impairment

- Behaviour: hypoactive
- Attitude: labil

Talk by
himself
Throwing
househol
d
Getting
angry
Poor
grooming

- Perception:
Hallucination of auditory
(+), visual (+)
- Thought Progression:
Remming
- Form of Thought: non
realistic
- Content of thought:
delusion of magic
mystic, thought
insertion, thought
broadcasting
- Patients response to
question: fair

- Poor
grooming
- Can not
communica
te well with
other

Syndrome
- Delusion of control, Delusion of
magic mystic
- Hallucination of auditory (+),
visual (+)
- Remming
- Poor grooming
- Thought insertion, thought
broadcasting

Psychotic
syndrome

Paranoid
syndrome

DIFFERENTIAL
DIAGNOSIS
F20.0
F06.7

Schizophrenia Paranoid (late onset)


Mild Cognitive Impairment

MULTIAXIAL
DIAGNOSIS
Axis I
: F20.0 Schizophrenia
Paranoid (late onset)
Axis II
: no diagnosis
Axis III
: TBC
Axis IV
: Lives alone
Axis V
: GAF admission 70-61

Patients problems
Biological problem
Psychotic symptom : neurotransmitter
imbalance in cerebral cortex

Psychological problems
He feels lonely because left by his family
and lives alone

Social Problem
He cant communicate well with others,
leisure time with family is diminished

MANAGEMENT

PLANNING
MANAGEMENT
Inpatient (hospitalization):

Talk by Himself
Throwing Household
Getting angry
Poor grooming

Response

Remiss
ion

Recove
ry

Response Phase
Target therapy :
50% decrease of symptoms
Emergency department
There is no emergency situation
Maintenance
Haloperidol 1,5 mg po 2dd1
Re-assess patient

Remission Phase
Target therapy :
100% remission of symptom

Inpatient management
Risperidone 2mg 1dd1 (decrease the side effect for
long-term antypsycotic usage)
Piracetam 800 mg 2dd1
Improving the patient quality of life :
Teach patient about her social & environment (interact with
her family and child, socialize with her neighbor or friends,
find a hobby to do on her spare time)

Outpatient management
Pharmacotherapy
Psychosocial therapy

Recovery Phase
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

Family education
All people have a chance to have psychiatric
problem
Psychiatric problem caused by multifactorial
Most of psychiatric problem cause by imbalance of
neurotrasmitter in brain
Psychiatric symptom can be controlled by drugs
Treat patient as a normal person
Please, only help patient if she/he really need help.
Dont ask patient to understand the family
situation, but the family must understand the
patient situation.
Dont get easily angered to the patient.

Thank You

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