*MORNING REPORT

Thursday afternoon, 02 January 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

I. PATIENTS IDENTITY
Autoanamnesis
Name
: Mr. H
Age
: 29 years old
Gender
: Male
Address
: Tegal
Occupation
: Driver
Marital status
: single
Last education
: Elementary School
Alloanamnesis
Name
: Mr. W
Age
: 54 years old
Relation
: his uncle

REASON WHY PATIENT

BROUGHT TO HOSPITAL
Angry and Hurt himself

*Present History
2
2 week
week ago
ago

Day
Day of
of
admission
admission

Easily get angry

Broke his furniture at home and his
grand mother house
He was Wandering and could not go
back home
He refused to work

Hurt himself and start to burn his

hair
Laugh his own self

Poor utilization of leisure time

Poor utilization of leisure time

poor grooming

poor grooming

Psychiatry
history

Patient has been hospitalized fourth

time in RSJS Magelang

Hypertension (-)
Head injury (-)
Convulsion (-)
Asthma (-)
Allergy (-)

General
medical history

Drugs and
alcohol abuse
history and
smoking history

Drugs consumption (-)

Alcohol consumption (-)
Cigarette Smoking (+)

*EARLY CHILDHOOD PHASE (0-3

YEARS OLD)

Psychomotoric
Psychomotoric (UNVALID
(UNVALID DATA)
DATA)
There
There were
were not
not get
get important
important data
data on
on patients
patients growth
growth and
and development
development such
such as:
as:

first
first time
time lifting
lifting the
the head
head (3-6
(3-6 months)
months)
rolling
over
(3-6
months)
rolling over (3-6 months)
Sitting
Sitting (6-9
(6-9 months)
months)
Crawling
(6-9
Crawling (6-9 months)
months)
Standing
Standing (6-9
(6-9 months)
months)
walking-running
walking-running (9-12
(9-12 months)
months)
holding
objects
in
his
hand(3-6
holding objects in his hand(3-6 months)
months)
putting
everything
in
his
mouth(3-6
putting everything in his mouth(3-6 months)
months)

Psychosocial
Psychosocial (UNVALID
(UNVALID DATA)
DATA)
There
There were
were not
not get
get important
important data
data on
on which
which age
age patient
patient

started
started smiling
smiling when
when seeing
seeing anothers
anothers face
face (3-6
(3-6 months)
months)
startled
by
noises(3-6
months)
startled by noises(3-6 months)
when
when the
the patient
patient first
first laugh
laugh or
or squirm
squirm when
when asked
asked to
to play,
play, nor
nor playing
playing claps
claps with
with others
others
(6-9
months)
(6-9 months)

Communication
Communication (UNVALID
(UNVALID DATA)
DATA)
There
There were
were not
not get
get important
important data
data on
on when
when patient
patient started
started saying
saying words
words 1
1 year
year like
like mom
mom
or
dad.
(6-9
months)
or dad. (6-9 months)

Emotion (UNVALID DATA)

There were not get important data of patients reaction
when playing, frightened by strangers, when starting to
show jealousy or competitiveness towards others and toilet
training.
Cognitive (UNVALID DATA)
There were not get important data on which age the
patient can follow objects, recognizing his mother,
recognize his family members.
There were not get important data on when the patient
first copied sounds that were heard, or understanding
simple orders.

* INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor
Psychomotor (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data on
on when
when patients
patients first
first time
time riding
riding a
a
bicycle,
bicycle, if
if patient
patient ever
ever involved
involved in
in any
any kind
kind of
of sports.
sports.
Psychosocial
Psychosocial (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data on
on patient
patient interaction
interaction with
with his
his
surrounding,
surrounding, not
not get
get important
important data
data on
on when
when patient
patient first
first
entered
entered primary
primary school,
school, how
how well
well he
he play
play with
with his
his new
new friend
friend on
on
first
first day
day school.
school.
Communication
Communication (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data regarding
regarding patient
patient ability
ability to
to make
make friends
friends
at
at school
school and
and how
how many
many friends
friends patient
patient have
have during
during his
his school
school
period
period
Emotional
Emotional (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data on
on patients
patients adaptation
adaptation under
under stress,
stress,
any
any incidents
incidents of
of bedwetting
bedwetting were
were not
not known.
known.
Cognitive
Cognitive (UNVALID
(UNVALID DATA
DATA ))

*LATE CHILDHOOD & TEENAGE PHASE

Sexual
Sexual development
development signs
signs &
& activity
activity (UNVALID
(UNVALID DATA)
DATA)
No
No data
data on
on when
when patient
patient experience
experience wet
wet dream,
dream, hair
hair on
on
armpits
armpits and
and pubis,
pubis, etc
etc
* Psychomotor
Psychomotor (UNVALID
(UNVALID DATA)
DATA)
No
No data
data if
if patient
patient had
had any
any favourite
favourite hobbies
hobbies or
or games,
games, if
if patient
patient
involved
involved in
in any
any kind
kind of
of sports.
sports.
* Psychosocial
Psychosocial (UNVALID
(UNVALID DATA)
DATA)
Patient
Patient had
had never
never been
been told
told family
family about
about patients
patients friend.
friend.
* Emotional
Emotional (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data on
on patients
patients reaction
reaction on
on playing,
playing, scared,
scared,
showed
showed jealously
jealously or
or competitiveness
competitiveness
* Communication
Communication (UNVALID
(UNVALID DATA)
DATA)
not
not get
get important
important data
data on
on how
how well
well the
the relationship
relationship between
between
patient
patient with
with parent
parent and
and his
his family.
family.

*ADULTHOOD
Educational History
Elementary
Elementary School
School

Occupational history

Driver
Driver and
and now
now not
not work
work

Marital Status
single
single

Criminal History
No
No

Social Activity

Patient
Patient had
had introvert
introvert personality,
personality, and
and he
he had
had a
a good
good relationship
relationship with
with his
his
neighbour.
neighbour.

Current
Current Situation
Situation

He
He lives
lives with
with his
his family
family

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

Family
history
history

*Patient is the second child of 4 siblings.

*Theres no psychiatry history in the
family.

*Psychosexual History
* He attracted a women but he did not dare
to confess.

*Genogram

Socio-economic history
Economic scale : no data
Validity
Alloanamnesis : valid
Autoanamnesis : unvalid

*Progression of disorder
Sympto
m

2011

Role function

2012

2014

Mental State
(Saturday afternoon, 28th december
2013)

Appearance
Look a man, appropriate to his age, completely
clothed

State of Consciousness
Clear

Speech
Quantity : Increased
Quality : Decreased

Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism

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

ATTITUDE
Cooperative
Non-

cooperative
Indiferrent
Apathy
Tension
Dependent
Active
Passive

(+)

Infantile
Distrust
Labile
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excitement

Emotion
Affect

Mood

Dysphoric (+)
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be
assessed

Appropriate
Inappropriate (+)
Restrictive
Blunted
Flat
Labile

Disturbance of perception
Hallucination

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

Illusion

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

Thought progression
Quantity

Logorrhea
Blocking
Remming
Mutisme
Talk active (+)

Quality

Irrelevan answer
Incoherence
Flight of idea
Over-valued idea
Confabulation
Poverty of speech
Loosening of association
Neologisme
Circumtansiality
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia

Content of thought

Idea

of Reference

Preoccupation

Obsession

Delusion of grandiose (+)

Delusion of Control
Delusion of Influence
Delusion of Passivity

Phobia

Delusion

of Persecution

Delusion of Perception

Delusion

of Reference

Thought of Echo

Delusion

of Envious

Thought of Insertion (+)

Delusion

of Hipochondry

Thought of Broadcasting

Delusion

of magic-mystic (+)

Form of Thought

Realistic
Non Realistic
Dereistic
Autistic

Sensorium and Cognition

Level of education
: Senior high school
General knowledge
: enough
Orientation of time/place/people/situation:
good/good/good/good
Working/short/long memory
: good
Writing and reading skills
: not examined
Visuospatial
: not examined
Abstract thinking
: not examined
Ability to self care
: bad

Impulse control when

examined

Self control: enough

Patient response to
examiners question:
enough

Insight

Impaired insight (+)

Intelectual Insight
True Insight

Internal Status

Conciousnes

Vital sign :

: compos mentis

Blood pressure
: 120/80 mmHg
Pulse rate
: 80 x/mnt
Temperature
: afebris
RR
: 20x/mnt

Head
Head :: normocephali
normocephali

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

Neck
Neck :: normal,
normal, no
no rigidity,
rigidity, no
no palpable
palpable lymph
lymph nodes
nodes

Thorax:
Thorax:
Cor
Cor

:: S
S 1,2
1,2 Sound
Sound and
and normal
normal

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

Abdomen
Abdomen

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

sound
sound

Extremity
Extremity

:: Warm
Warm acral,
acral, capp
capp refill
refill <2
<2

* Motoric: Normotonus, good coordination of

movement
* Physiological reflex:
Biceps +/+, Triceps +/+, KPR +/+
* Pathological reflex:
Hoffman-Tromer -/-, Babinski -/-,
Chaddock -/-,

Neurological exam :

RESUME
Symptoms

Mental
Status

Impairment

Easily get angry

Laugh his own self
Broke his furniture at
home and his grand
mother house
He was Wandering and
could not go back home
He refused to work
Hurt himself and start
to burn his hair
Laugh his own self

cooperative
Inappropiate
Thought insertion
Delution of grandious
Delution of magic
mistic
Non realistic
Impaired insight

Poor utilization
of leisure time
Poor grooming

Differential Diagnose

F25.2 Schizoaffective mixed type

F31.2 Bipolar affective

disorder,present manic episode with

psychotic symptoms

Multiaxial Diagnose
Axis I
Axis II
Axis III
Axis IV
Axis V

: F25.2 Schizoaffective mixed type

: R46.8 delayed diagnosis of axis II
: No diagnose
: Psychosocial and environmental problems
: GAF admission 20-11

Therapy

Hospitalization

purpose

of hospitalization is to decrease
the symptoms, so patient can handle
herself, and not threatening people
around her.
Hospital treatment plans should be
oriented toward practical issues of quality
of
life,
role
function
and
social
relationships.
To establish an effective association
between patients and community support
systems.

*PLANNING MANAGEMENT
Pharmacothisapy
O Emergency therapy
O Inj. Haloperidol

5mg 1 ampul im

ORoutine therapy

O Haloperidol 2 x 5 mg
O Litium karbonat 1 x 400 mg

Psycho-education
Educate the patient and family after medication:
* Explain to patients family about mental
disorder. There are many factors cause the
symptoms..
* Treat the patient according to the familys
ability, dont demand the patient more nor less.
* Help the patient when she needs it.
* Education of the family to encourage
communication and understanding.

Ad vitam
: ad bonam
Ad functionum : dubia ad malam
Ad sanationum : dubia ad malam

*PROGNOSIS

Thank You