Monday night shift 15th September

2014

MORNING
REPORT

SUPERVISOR
dr. Sabar P. Siregar, S

Patient Identity
Name
Sex
Age
Address
Occupation
babysister)
Marital Status

:
:
:
:
:

Ms. Su
Female
37 years old
Temanggung
Unemployed ( used to be
: Single

RELATIVES IDENTITY

Name : Mr. Y
Sex : Male
Age : 61 years old
Relation : Father

Reason patient was brought to

emergency room
Patient was talking to herself,
laughing alone, getting angry easily

Present History

1 month
ago
(2014)

In August,
patient quit her
job as maid and
returned from
Semarang
because she was
feeling
unsatisfied with
her job

4 days
ago
(2014)

Patient asked for

permission to work in big
city but not allowed by
her parents. When
denied by her parents,
she started to get angry
easily.

Impairment :
Patient could not sleep and unable to
communicate well with others

2 days
ago
(2014)

Patient started to talk and

laugh by herself. At
night, patient could not
sleep and started
singing. Patient was tied
because she tried to
leave home.
Impairment :
Patient could not sleep and unable to
communicate well with others
Patient could not take care of herself
(refused to bathe and poor appetite)

Stressor
Patient was denied by her
parents to work in big city.

Day of Admission

15th September
2014

Brought
to the
hospita
l by her
father
(in tied
conditi
on)

Brought to the
hospital
because
patient talked
and laughed
by herself

PSYCHIATRIC HISTORY

Since 1991 patient was admitted

in RSJ for 5 times for same
reason

EARLY CHILDHOOD PHASE (0-3 YEARS

OLD)
Psychomotoric
- There were no valid data on patients growth and development because
her father
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
- There were no valid data on patients growth and development because
her father
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
- There were no valid data on when patient started bubbling
because her father couldnt remember. (6-9 months)
Emotion
- There were no valid data on patients reaction when playing,
frightened by strangers, when starting to show jealousy or
competitiveness towards other and toilet training because
her father couldnt remember
Cognitive
There were no valid data because her father couldnt
remember, such as:
- which age the patient can follow objects, recognizing his
mother, recognize his family members.
- when the patient first copied sounds that were heard, or
understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS

OLD)
Psychomotor

Psychomotor
No valid data on when patients first time playing hide and
seek, but patient was involved in certain kind of sports.
Psychosocial

She never involved in a fight with other kids.

Communication
She has few friends at school during childhood.
Emotional
She was a quiet kid.
Cognitive
She was an average and diligent student.

LATE CHILDHOOD & TEENAGE

PHASE
Sexual development signs & activity
No data
opposite

on when patient get her menarche. She is attracted to

sex.

Psychomotor
She often involved in household chorus like cooking
Psychosocial
She dropped out after elementary school and started working as a
babysister
Emotional
She was a quite girl.
Communication
Patients has a few friends

ADULTHOOD

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 2nd child among 3
siblings
Psychiatry history in the family
(-)

Genogram

MALE

FEMALE

PATIENT

LIVE
TOGETHER

PSYCHOSEXUAL
HISTORY
Patient realizes that she is female, and has interests to
male. Her attitude is appropriate as a female.

Progression of Disorder
Symptom1991

Role Function

March
2014

Now

Mental State
15th September 2014

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism

Command
automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggressive
Impulsive
Abulia

ATTITUDE

Indiferrent
Apathy
Tension
Dependent
Passive
Non
cooperative

Infantile
Distrust
Labile
Passive negativism
Catalepsy
Cerea flexibility
Excited

Emotion

Disturbance of Perception

Depersonalization (-)

Derealization (-)

Thought Progression

Content of Thought

Can not be assessed

Delusion of grandiose

Idea of Reference

Delusion of Control

Idea of Guilt

Delusion of Influence

Preoccupation

Delusion of Passivity

Obsession

Delusion of Perception

Phobia

Delusion of Suspicious

Delusion of Persecution

Thought of Echo

Delusion of Reference

Thought of Insertion &

Delusion of Envious

Delusion of Hipochondry

Delusion of magic-mystic

withdrawal
Thought of Broadcasting

Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition

Level of education
: Elementary school
General knowledge : cant be assessed
Orientation of time
: bad
Orientations of place
: good
Orientations of people
: good
Orientations of situation : bad
Working/short/long memory: good
Writing and reading skills : good
Visuospatial
: cant be accessed
Abstract thinking
: cant be accessed
Ability to self care
: poor

Physical State
Consciousnes
Vital sign :

: compos mentis

Blood pressure
Pulse rate
Temperature
RR

:
:
:

: 113/87 mmHg
92 x/mnt
Afebris
24 x/mnt

Review System

Head

: normocephali, mouth deviation (-)

Eyes

: anemic conjungtiva (-), icteric sclera (-), pupil

isocore

Neck

Thorax

: normal, no rigidity, no palpable lymph nodes

:

Cor

: S 1,2 regular

Lung

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

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

Extremity : Warm acral, capp refill <2

Neurological exam : not examined

RESUME
A female, 37 years old, appropriate
according to her age
Reason to be brought to hospital : Patient
talked, laughed by herself, and easy to get
angry
She has been singing loudly at night,
difficulty in falling asleep, loss of appetite,
poor self-care

Mental
Status
Talking and
laughing by
herself
Singing
loudly at
night
Getting
angry easily

-Behavior: hyperactive,
aggressive, impulsive
-Attitude: excited
-Affect: inappropriate,
elevated
-Mood : irritable
-Thought progression:
- Quantity : logorrhea
- Quality : loosening
of association,
irrelevant answer
-Form of thought: non
realistic
-Content of thought :
delusion of grandiose
-Patients response to

Impairment

She couldnt
sleep
She couldnt
communicate
well with
others
Poor self-care
Loss of
appetite

Differential Diagnosis
F 25.0 Schizoaffective Disorder ManicTyped
F 31.2 Bipolar Affective Disorder, Current
Manic Episode with Psychotic
Episode

Multiaxial Diagnosis
Axis I
Axis
Axis
Axis
Axis

: F 25.0 Schizoaffective Disorder Manic

Typed
II
: Z 03.2 No diagnosis
III : No diagnosis
IV : Denied by her parents to work in big
city
V : GAF admission 40-31

Problem related to the patient

- Patient left her job because she was not satisfied
with the job- Patients parent not allowing her to work
in big city

PLANNING
MANAGEMENT

Inpatient (hospitalization)

Aggressive
Poor self-care
Logorrhea

RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Haloperidol
5mg i.m
Diazepam
10mg i.v
Maintenance
Haloperidol 2 x 5 mg
Re-assess patient

REMISSION PHASE

Target therapy :
100% remission of symptom

Inpatient management
Continue the pharmacotherapy: maintenance
Haloperidol 2 x 5 mg
1.Improving the patient quality of life :
Teach patient about his social & environment
(interact with her parents, socialize with her
neighbor, get a job, find a hobby to do in his spare
time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

RECOVERY PHASE
- Continue the medication, control to
psychiatric
-Rehabilitation : help patient to find a hobby
and productive skill, help patient to interact
normally with her family and neighbor
-Family education :
- explain to the family about the mental
disorder and the treatment.
-Educate the family to support not to exile
the patient.
-Ask the family to monitor patient progress
and make sure the patient take medicine as
prescribe.

Thank you