Morning Report

Saturday, June 9,2012 Supervisor : dr Sabar P Siregar Sp.Kj

I.Patients Identity
Name Age Gender Address Occupation Marriage status Religion Last education : Mr. T : 25 years old : Male : Purbalingga : Unemployee : Single : Moeslem : Elementary School

Alloanamnesis Name : Mr. S Relation : Patients father

II.Chief complaint

Talk and laugh to himself

History of Presenting Illness

6 years ago (2006)
family often saw patient talk to himself Laugh to himself

1 years ago ( 2011) Patient talk to himself

 10 years ago

complaints are not reduced -patient gave birth to first child -patients brought to the traditional healer (dukun) but not change
-

7 years ago
husband ran away from home because the complaints of patients is not reduced Patient gave birth the second child

5 years ago
patient's husband returned home and taken away to pick up their children patients suffering from chronic cough for 1 month and was hospitalized for 2 weeks in Nirmala hospital

1,5 month ago

- rampage - disturbing the environment - cooped up - monologue/talk to her self - laughed to herself - unable to care for herselves - not eating - wander

Past Medical History

Organic Disease (+)chronic cough for a month (2007) Head injury (-) Convulsion (-)

Psychoactive Substance Use

Alcohol consumption (-) Tobacco consumption (-) drug use (-)

History of Personal Life

PRENATAL AND PERINATAL HISTORY born normally EARLY CHILDHOOD HISTORY crawling, walking, normal communication,motor development, emotional,visual and normal cognitive MIDDLE CHILDHOOD HISTORY Patient graduated from elementary school. Patient was a quiet person. LATE CHILDHOOD HISTORY Patient didnt have a lot friend, shy and quiet person.

History of Adulthood
HISTORY OF EDUCATION Patient graduated from elementary school . HISTORY OF JOB She is an umployee since 10 years ago HISTORY OF MARRIAGE patient married with the first husband 11 years ago, patient's husband passed away and patient got married with her brother in law.with the second husband patient had 2 children HISTORY OF RELIGION Moeslim. Pray rarely. HISTORY OF VIOLATIONS OF LAW No history. HISTORY OF PSYCHOSOCIAL No data

Social and Economy

Patient is a housewife Patients economic is moderate to low

Level of convidence
Alloanamnesis Autoanamnesis : can be trusted : cant be trusted

Family History
Patient is the 4th children from 5 siblings The patients has married with the 1st husband in 2001 but 1 year after that,the husband was passed away 10 days after her husband was passed away,the patients got married with brother in law with a forced From the 2nd husband patient got 2 children Theres no family with the same complaint with the patient

Genogram

patient Man Woman Passed away

Progression of Ilness

symptom

2001

2002

1,5 month

now

Role function

 III Mental State

Appearance : Female, appropriate according to age, dressed in red and purple scarf and less neat Level of Consciousness

Clear
Speech: Quantity Quality : low : low

Posture, Movements and Social Behaviour osture, Movements and Social Command automatism Normoactive
Hypoactive Hyperactive Echopraxia Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia

Posture, Movements and Social Behaviour

Cooperative Non-cooperative Indiferrent Apathy Tension Dependent Active Passive

Infantile Distrust Labile Rigid Passive negativism Stereotypy Catalepsy Cerea flexibility

Emotion
Mood
Euthymic Dysphoric Euphoria Elevated Expansive Irritable Cant be assesed

Affect
Appropriate Inappropriate Restrictive Blunted Flat Labile

Disturbance of perception
Hallucination
Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cant be assesed

Illusion
Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-) Cant be assesed

Depersonalisasi (-)

Derealisasi (-)

Though Progression of though

Quantity Quality
Coherence Incoherence

Logorrhea Blocking Remming Mutisme Talk active

Flight of idea
Confabulation Poverty of speech Loosening of association Neologisme Circumtansiality Verbigration Sound association Perseveration Word salad Echolalia

Irrelevance answers

D. Thought Process
Form of Thought

Realistic Non Realistic Dereistic Autistic

 Idea of reference

Delusion of magic-mistic

Preokupasi
Obsesi Fobia Waham nihilistik Delution of suspicious Delution of envious Delution of hipokondri

Delusion of control
Delusion of influence Delusion of passivity Delusion of perception Thought of echo Thought of insertion/withdrawal Thought of broadcasting

E. SENSORIUM and cognition

Level of education School General knowledge Orientation of time place people Working/short/long memory Writing and reading skills Visuospatial Abstract thinking Ability to self care : Elementary : Low : Bad : Bad : Bad : Bad : No Data : No Data : No Data : Bad

Impulse control when ex amed

Enough

Insight

Impaired insight Intelectual Insight True Insight

Internal Status
Conciousness : compos mentis Vital sign:
Blood pressure : 120/80 mmHg Pulse rate : Temperature : afebris RR: : 22x/mnt

 Head : normocephali Eyes anemic conjungtiva -/-, icterik sclera -/-, pupil isocore Neck : normal, no rigidity, no palpable lymphnode Thorax: No Data Abdomen : Pain - , peristaltic normal, thympany sound Extremity : warmth acral

Neurological status
Motoric : normotonus, good coordination of movement Physiological reflex : +/+ Pathological reflex : -/Ro Thorax : Delayed

Resume
Perception disorder - auditory hallusination
family often see patient talk to herself but when we ask and try to get the information from patient in IGD, she denied it - visual hallusination family often see patient talk to herself but when we ask and try to get the information from patient in IGD, she denied it

Thought process - Though progression quantitative Remming Qualitative Coheren - Form of though

: Autistic

Differential Diagnose
F20.2 Katatonik Schizophrenia F20.0 Schizophrenia Paranoid F20.3 Undifferentiated Schizophrenia

Multiaxial Diagnose
Axis I : F20.2 cataton Axis II : Delayed Axis III : Delayed Axis IV : problems with primary support group;husband passed away without the knowledge of the patient and the patient was forced to married her brother-in-law Axis V : GAF 30-21

Therapy
Hospitalized Medication
Initial Therapy: Haloperidol 1 amp i.m Diazepam 1 amp i.v Maintenance: Risperidon 2 x 2 mg

Family Education
Explain to her family about this patient mental disorder Describes steps of treatment Family must maintain the patients drugs consumption and routine doctor consultation , so it will increase the efficacy of treatment familiy must keep in touch with patient intensively, so the patient will not feel lonely