MORNING REPORT SATURDAY, 2nd October 2013

Author: Hengki Eksar Aritama Moch Rizki Destiantoro Gabriela Eneria Sibarani Ni Putu Surya Diana

20080310046 (FKIK UMY) 20080310129 (FKIK UMY) 0961050125 (FK UKI) 0961050128 (FK UKI)

Supervisior: Dr. Sabar P Siregar, Sp.KJ

KEPANITERAAN KLINIK ILMU KEDOKTERAN JIWA RSJ PROF. DR. dr. SOEROJO MAGELANG 2013

1. PATIENTS IDENTITY Name Age Gender Address Occupation Marriage status Last education : Mr. R : 33 years old : Male : Pemalang : Fishismen : Married : Senior High School (graduated)

Alloanammnesis Name Address Relationship : Mrs.C : Pemalang : Aunt

2. PSYCHIATRIC HISTORY Major Complaint Angry (punch his neighborhood)

Presenting History The patient was brought by his family to RSJS because angry without reason and punch his neighboor. Patient start change 2 month ago when patient start stopung working without reason. This is happening since 1 weeks ago. Patient had lake to sleep and often wandering around..Patients often go to neighbors then get angry for no reason. His parent difficult to asked his for eat, drink and take a bath. If she warned she will angry and rage. Patient lock hisself in room for long time. Patient had been seen by a physician or psychologist but not well. Patients had hospitalization 7 times with the same symptoms. The last hospitalization on May and relieve on June 2013. A patient routinely taking medication but the longer the patient does not want to take medication anymore because he felt she had recovered.

1 month before entering the mental hospital the patient's symptoms persist and often angry and cannot be controlled. Patients rampage to neighbors to threaten to kill him.

Past History Psychiatry History 7 times hospitalization with same symptoms in RSJS

General Medical History Febrile Seizure (-) Head injury (-) Typhoid fever and seizure complication (7 years ago)

Drugs and alcohol abuse history and smoking history Alcohol consumption (-) Cigarette Smoking (-)

3. FAMILY HISTORY Patient is the first child of 2 children and no psychiatry history in the family. Genogram

4. HISTORY OF PERSONAL LIFE PRENATAL AND PERINATAL HISTORY Conditions & nutrition during the mothiss pregnancy is good and normal labor by dukun. EARLY CHILDHOOD PHASE (0-3 YEARS OLD) Psychomotoric (NORMAL) Patient had walking at 12 months years old Psychosocial (NO VALID DATA) Thise were no valid data on which age patient started smiling when seeing anothis 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 othiss (6-9 months) Communication (NO VALID DATA) Thise were no valid data on when patient started saying words 1 year like mom or dad. (6-9 months) INTERMEDIATE CHILDHOOD (3-11 YEARS OLD) Psychomotor (NO VALID DATA) No valid data on when patients first time riding a tricycle or bicycle, if patient ever involved in any kind of sports. Psychosocial (NORMAL) Patient first entered primary school in 6th years old, how well patient handles separation from parents, how well she plays with new friends on first day of school Communication (NO VALID DATA) Thise were no valid data regarding patients ability to make friends in school, and how many friends patient have during his schooling period. Emotional (NO VALID DATA) No valid data on patients adaptation under stress, any incidents of bedwetting were not known. Cognitive (NORMAL) Patients achievement in school, how well patients reading ability and grades.

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NORMAL) patient experience menarche in 11th years old Psychomotor (NO VALID DATA) No data if patient had any favourite hobbies or games, if patient involved in any kind of sports. Psychosocial (NO VALID DATA) No data if while growing up did he make many friends, how well patient make any friends and how much friends. No valid data on when and how patients relationship with different gender, if patient ever had any relationship with the opposite gender. Emotional (NO VALID DATA) No data if patient ever told friends or family regarding any problems. No data if patient attempted to break the rules (truant schools subject, fight with friends, bullying, etc) and consuming alcohol, smoke and drugs Communication (NO VALID DATA) No valid data on how well the relationship between patient with parents and othis family. ERIKSONS STAGES OF PSYCHOSOCIAL DEVELOPMENT Stage Infancy (birth to 18 months) Early childhood (2-3 years) Preschool (3-5 years) School age (6-11 years) Adolescence (12-18 years) Basic Conflict Trust vs mistrust Important Events Feeding Associated Virtue Hope

Autonomy vs shame and doubt Initiative vs guilt

Toilet training

Will

Exploration

Purpose

Industry vs inferiority

School

Competence

Identity vs role confusion

Social relationships

Fidelity

Young Adulthood (19-40 years) Middle adulthood (40-65 years) Maturity (65- death)

Intimacy vs isolation

Relationship

Love

Generativity vs stagnation Ego integrity vs despair

Work and parenthood

Care

Reflection on life

Wisdom

5. SOCIO-ECONOMIC HISTORY Economy scale: low 6. VALIDITY Alloanamnesis : Valid Autonamnesis : Valid 7. PROGRESSION OF ILLNESS

8. MENTAL STATUS (Saturday, 28th September 2013, 19.10 WIB) Appearance : Female, appropriate according to his age, wears complete attire State of Consciousness clear Speech: Quantity

: decreased

Quality

: decreased

Behaviour: Hypoactive Normoactive Hyperactive Echopraxia Catatonia Negativism Impulsive Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Abulia Attitude: Cooperative Non-cooperative Indifferrent Apathy Tension Dependent Active Passive Emotion: Mood Dysphoric Elevated Euphoria Expansive Agitation Afek Appropriate Inappropriate Restrictive Blunted Flat Labile Infantile Labile Rigid Active negativism Stereotypy Catalepsy Cerea flexibility Cataplexy Stereotypy Mannerism Automatism Automatism Command automatism Mutism Akathisia

 DISTURBANCE OF PERCEPTION Illusion Auditory (-) Visual (+) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Hallucination Auditory (+) Visual (+) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Depersonalisation (-) Derealisation (-)

TOUGHT OF PROGRESSION Quality Irrelevant Incohisence Flight of idea Confabulation Poverty of speech Verbigration Sound association Loosening of association Neologisme Circumtansiality Tangentiallity Perseveration Word salad Echolalia CONTENT OF THOUGH Delusion of influence Delusion of passivity Delusion of perception Delusion of grandeur Delusion of bizzare : Thought of echo Thought of insertion Thought of broadcasting Idea of reference Idea of guilty Preoccupation Obsessive Phobia Delution of reference Delution of hypocondry Delusion of magic-mistic Delusion of control Quantity Logorrhea Blocking Remming Mutisme Talk active

 THOUGH FORM Realistic Non Realistic Dereistic Autistic

SENSORIUM AND COGNITION Level of education General knowledge : junior high school (not graduated) : poor

Orientation of time/place/people/situation: bad/bad/bad/bad Working/short/long memory Writing and reading skills Visuospatial Abstract thinking Ability to self care : bad/bad/bad : not examined : good : poor : poor

9. INTERNAL STATUS Conciousnes : compos mentis Vital sign : a. Blood pressure : 119/76 mmHg b. Pulse rate : 109 x/mnt c. Temperature : 36,8 C d. RR : 18 x/mnt Head : normocephali Eyes : anemic conjungtiva -/-, ikteric sclera -/-, pupil isocor Neck : normal, no rigidity, no palpable lymph node Thorax : Cor : S1 and S2 sound and normal Lungs : vesicular sound, wheezing -/-, ronchi-/ Abdomen : pain -, peristaltic normal, thympany sound (+) Extremity : warm acral, cappillary refill < 2 second

10. RESUME SYMPTOMS: Agitated Irritable Sleep less Wandering around Anger without reason Disturb his neighborhood MENTAL STATUS: Impulsive Non cooperative Blunted Inappropriate Catalepsy Remming

Irrelevant of answer Idea of reference Thought insertion Non realistic Auditoric hallucination Visual halluscination Visual Illusion

IMPAIRMENT: Role and social dysfunction Normal self grooming 11. DIFFERENTIAL DIAGNOSIS - F20.0 Skizofren Paranoid - F06.0 Halusinasi organik - F20.3 Skizofren unspecified 12. MULTIAXIAL DIAGNOSE Axis I Axis II Axis III Axis IV Axis V : F.20.0 Skizofren Paranoid : Z03.2 no diagnosis : A00-B99 and G00-G99 (thypoid infection history and seizure history) : disorder medication adhisence because lack of family support : GAF 20-11

13. PLANING MANAGEMENT - Hospitalization

Pharmacothisapy Psychothisapy Psycho-education

Hospitalization O The purpose of hospitalization is to decrease the symptoms, so patient can handle hisself . O Patient is a danger to othiss because she disturbed his neighborhood

Pharmacothisapy O Emergency thisapy Extra Diazepam 10mg/ IV Extra Haloperidol 5mg/ IM O Routine thisapy Haloperidol 2x5mg Psychothisapy O Give motivate and spirit to the patient for medication adhisence Psycho-education (Family) O Educate the family to more medication adhisence O Explain the importance of support from family and how the family members give care to the patient O Help the patient if needed.