MORNING

REPORT
Tuesday 20th September 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

PATIENTS IDENTITY
Name
: Mr. AA
Sex
: Male
Age
: 22 years old
Address
: Srumbung, Magelang
Occupation
: Unemployed
Marital State
: Single

RELATIVEs
IDENTITY
Name: Mr. M
Sex : Male
Age
: 44
years old
Relation : His
father

Name: Mrs.SA
Sex: Female
Age : 40
years old
Relation : his
Mother

THE REASON PATIENT WAS

BROUGHT TO EMERGENCY ROOM

Patient has been :

Lack of sleep
Talked by himself
Laugh by himself
Easily get angry
Destructive many things
Shut himself

STRESSOR

- he was under pressure

from his superiors when
he worked in jakarta, and
he didnt get a salary

PRESENT HISTORY
1 year ago
Lack of
sleep,
Easily to
get anger,
talked and
laugh by
himself,
destructiv
e acting,
and shut
himself.

Patient
brought to
RSUD
Muntilan
then got
medicine

But he didnt
consume
that
madicine

PRESENT HISTORY
September 2014
Patient said
that he often
see a women
Finally he
and heard a
brought to
whisper from
RSJS
the outside, but
Magelang
he didnt know
by his
that anyone. He
parent
also believed
with the
that everyone
same
on the TV would
symptoms
hurt and kill
him.
20th

The
symptom
s getting
worse

PSYCHIAT
RIC
HISTORY

There is no psychiatri
history

General
Medical
History

Head injury (-) -Asthma (-)

Hypertension (-) -Allergy (-)
Convulsion (-)
Tbc (+)
katarak operation (+)

Drugs & Alcohol

Abuse &
Smoking History

Drugs consumption (-)

Alcohol consumption (+) only
one time
Cigarette Smoking (+)

EARLY CHILDHOOD PHASE (0-3 YEARS

OLD)
Psychomotoric (No Valid Data)
- There were no valid data on patients growth and
development such as:
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 (No Valid Data)
- There were no valid data on which age patient
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)

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)

Psychomotor (NO VALID DATA)
No valid data on when patients first time playing
hide and seek or if patient ever involved in any kind
of sports.
Psychosocial
Patient was an uncommunicative and temperament
child, he sometimes fight with his friend
Communication
Patient was uncommunicative but he still can be
friends with the others.
Emotional
Temperament child.
Cognitive
Patients academic history was good, he always up
to a higher class, and he ever got a rank in his class

LATE CHILHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)
No data on patients sexual development sign and activity.
Psychomotor
The patients hobby is sport like chess, basket ball, and
football.
Psychosocial
No valid

(NO VALID DATA)

data regarding patient psychosocial.

Emotional
He was a Temprament people, he got the other fight with
his friends in a few month ago.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at
school and how many friends patient have during his high
school period

ADULTHOOD
Educational History
He graduated his
junior high school
and did not
continue his study
to senior high
school
Occupational
history
previously
He
worked at jakarta,
but
only
for
5
month, and now He
doesnt work
Marital Status
Single

Criminal History
No criminal
history
Social Activity
He has a lot of
friends.
Current Situation
He lives with His
parents, and her
brother and sister

ERIKSONS STAGES OF PSYCHOSOCIAL

DEVELOPMENT
(NO VALID DATA)
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
The patient is the 1st child and has a
3 siblings
Psychiatry history in the family (-)

Patient

GENOGRAM
MALE

FEMALE

Died
Mental disorder

Other Mental disorder

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

PROGRESSION OF DISORDER
2014

Symptom
2013

Role Function

MENTAL STATE

MENTAL STATE
Appearance

20th September 2014

A female, appropriate to her

age, completely clothed

State of Consciousness
Clear

Speech
Quantity
Quality

: Talkative
: Decreased

BEHAVIOUR
Hypoactive
Normoactive
Hyperactive
Echopraxia
Catatonia
Active
negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre

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

ATTITUDE

Non
Cooperative
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
Cant be
assesed

Inappropriate
Restrictive
Blunted
Flat
Labile

DISTURBANCE OF
PERCEPTION
H A L LU C I N AT I O N

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

Depersonalization (-)

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

Idea of Reference

Idea of Guilt

Preoccupation

Delusion of grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity

Obsession

Phobia

Delusion of Persecution Delusion of Suspicious

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of insertion

Delusion of Hipochondry

Thought of withdrawal

Delusion of magic-mystic

Thought of Broadcasting

Delusion of Perception

FORM OF THOUGHT
Non Realistic
Dereistic
Autism
Cannot be evaluated

SENSORIUM AND
COGNITION

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

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

Insight
IMPAIRED
INSIGHT
Intellectual
Insight
True Insight

PHYSICAL STATE
Consciousnes : compos mentis
Vital sign
Blood pressure
: 100/70
mmHg
Pulse rate
: 80 x/mnt
Temperature
: Afebrile
RR
: 20 x/mnt

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

Lung : vesicular sound, wheezing -/-,

ronchi-/ Abdomen

: Pain (-) , normal peristaltic,

RESUME
A man, 22 years old, appropriate
according to his age
Reason to be brought to hospital are:
Lack of sleep
Talked by herself
Laugh by himself
Easily get angry
Destructive many things
Shut himself

RESUME

Symptom
s
Lack of
sleep
Talked by
herself
Laugh by
himself
Easily get
angry
Destructiv
e many
things
Shut
himself

DAY OF ADMISSION

Mental
- Mood: dysphoric
- Affect:Status
inappropriate

- Behaviour: hypoactive,
manerism
- Attitude: passive, non
cooperative
- Perception: auditory and
visual hallucination
- Thought Progression:
remming, Poverty of
speech
- Form of Thought: non
realistic
- Content of thought:
Delusion of reference, and
delusion of persecution
-Patients response to
question: poor

Impairment

- Can not do
his daily
activity
properly
- Can not
communica
te well with
other

DIFFERENTIAL
DIAGNOSIS
F20.2 Catatonic Schizophrenia
F20.0 Paranoid Schizophrenia
F20.1 Hebefrenic Schizophrenia

MULTIAXIAL
DIAGNOSIS
Axis I
: F20.2 Catatonic
schizophrenia
Axis II
: Z 03.2 no diagnosis
Axis III
: no diagnosis
Axis IV
: Problem with
occupational and
psychosocial
Axis V
: GAF admission 40-31

PLANNING
MANAGEMENT
Inpatient (hospitalization):
Lack of sleep
Laugh by himself
Talked by herself
Easily get angry

Response

Remiss
ion

Recove
ry

RESPONSE PHASE
TARGET THERAPY : 50%
decrease of symptoms
EMERGENCY DEPARTMENT
Haloperidol
5 mg i.m
Diazepam
10 mg i.v
MAINTANCE
Haloperidol 5mg 2dd1
RE-ASSESS PATIENT

REMISSION PHASE
TARGET THERAPY
100% remission of symptom
INPATIENT MANAGEMENT
Continue the pharmacotherapy: maintenance
Haloperidol 5mg 2 dd1
Improving the patient quality of life :
Teach patient about his coping mechanism to
stress
(interact with his mother and family more,
pray and do social activities)
OUTPATIENT MANAGEMENT
1. Pharmacotherapy
2. Psychotherapy

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 :
- explain to the family about the mental
disorder and the treatment.
-Educate the family to support not to exile
the patient.
-Ask therapy
the family
monitor
patient
progress
Target
: 100%to
remission
of symptom
within
1 year.
and make sure the patient take medicine as
prescribe.

Thank you