MORNING

REPORT
Monday, 2nd september 2013

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ

I. PATIENTS IDENTITY
Autoanamnesis
Name
: Ms. N
Age
: 16 years old
Gender
: Female
Address
: Purworejo
Occupation
: Unemployee
Marital status
: Unmarried
Religion
: Moslem
Last education
: Senior High School
Alloanamnesis
Name
: Mr.Y
Age
: 54 years old
Relation
: Father

REASON WHY SHE BROUGHT

TO HOSPITAL

Raged, shouted,
wandering alone

Present History
2
weeks
ago

9 day
ago

Raged
Talk to herself
Insomnia
Decreased appetite
disturbing others
Afraid to people
arround her

Social withdrawal,dont want

to do household chores, good
utilization of leisure time,
good self grooming.

Angry without any

reason
Raged
Talk to herself
Afraid of people
arround her
Insomnia
Disturbing others
broke plates and cups
Didnt go to school

Social withdrawal, poor self

grooming.
Does
not
want
to
do
household
chores,
poor
utilization of leisure time

Day of
admission

Raged
shouted
Wandering
alone
Afraid to people
arround her
Insomnia
decreased
appetite

Social withdrawal, poor self

grooming.
Does not want to go to school,
poor utilization of leisure time

PAST HISTORY
Hypertension
(+)
Head injury (-)
Convulsion (-)
Asthma (-)
Allergy (-)

Dru
gs
an
d
alc
oho
l
ab
use
hist
ory
an
d
sm
oki
ng
hist
ory

no history
of
psychiatric
illness

Drugs
consumption
(-)
Alcohol
consumption
(-)
Cigarette
Smoking (-)

Ge
ne
ral
me
dic
al
his
tor
y

Ps
yc
hia
try
his
tor
y

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)
Communication (NO VALID DATA)
There were no valid data on when patient started saying words 1 year like mom
or dad. (6-9 months)

Emotion (NO VALID DATA)

There were no valid data of patients reaction when
playing, frightened by strangers, when starting to show
jealousy or competitiveness towards other and toilet
training.

Cognitive (NO VALID DATA)

There were no valid data on which age the patient can
follow objects, recognizing her mother, recognize her
family members.
There were no valid data on when the patient first
copied sounds that were heard, or understanding
simple orders.

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 (NO VALID DATA)
There were no valid data on patients gender identification, interaction
with his surroundings
There were no data on when patient first entered primary school, how
well patient handles seperation from parents, how well he plays with
new friends on first day of school
Communication (NO VALID DATA)
There 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 (NO VALID DATA)
No valid data on patients cognitive.

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)
No data on when patient experience wet dream, hair on armpits
and pubis, etc
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 other family.

ADULTHOOD
Educational History
senior high school (1 high school class)

Occupational history
Unemployee

Marital Status
Unmarried.

Criminal History
No

Social Activity
Before illness was normal

Current Situation
she lives with her father, her uncle, and her younger brother

Religious history
Pray routinely before illness

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

Conclusion: not clear data

Family History
Patient is the 1st child of 2 siblings.
Her father had a history of emotional

instability

Psychosexual history
Patient

psychosexual
history
is
appropriate of her gender and attracted to
man.

Genogram

:Female

: Patient

:Male

: RIP

Live together

Socio-economic history
Economic scale : poor

Validity
Alloanamnesis : valid
Autoanamnesis : valid

Progression of disorder
Sympto
m
2 weeks ago

Role function

9 days
ago

now

Mental State
(Monday, 2nd September 2013)
Appearance :
a woman, appropriate according to age, wear
complete clothes
State of Consciousness
Clear
Speech:
Quantity : decreased
Quality

: increased

Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre

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

ATTITUDE
Non-

cooperative
Indiferrent
Apathy
Tension
Dependent
Active
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excitement

Emotion
Affect

Mood

Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
agitation
Cant be assesed

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
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
think fast

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

Delusion of suspicious

Delusion

of Envious

Thought of Echo

Delusion

of Hipokondry

Thought of

Delusion

of magic-mystic

Insertion/withdrawal
Thought of Broadcasting

Thought process
Realistic
Non Realistic
Dereistic
Autistic

Sensorium and Cognition

Level of education : enough

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

Insight
Impaired insight
Intelectual Insight
True Insight

Impulse control when

examined
Self control: poor
Patient response to
examiners question:
poor

Internal Status
Conciousnes
Vital

: composmentis

sign :

Blood pressure : 140/90 mmHg

Pulse rate
: 135x/mnt
Temperature
: afebris
RR
: 30x/mnt

Head : normocephali

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

isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax:
Cor

: S 1,2 Sound and normal

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

Abdomen

: Pain (-) , normal peristaltic, tympany

sound

Extremity

: Warm acral, capp refill <2

RESUME
Onset : 2 weeks ago
Symptoms
Angry without
any reason
shouted
Raged
Talk to himself
Afraid to
people arround
her
Insomnia
decreased
appetite

Mental
Status

Disabilit
y

Hyperactive, agitation,
Aggressive,
inappropriate,
Halucination of visual
and auditoric, ,
Delusion of
suspicious,, Impaired
insight

Social
withdrawal,
poor self
grooming, do
not want to
go to school,
decrease
appetite

Differential Diagnose
F20.0 paranoid schizophrenia
F23.2 acute psychotic disorder lir-

schizophrenia
F32.3 severe depressive episode
with psychotic symptoms

Multiaxial Diagnose
Axis

: F23.2 acute pschycotic disorder lirschizophrenia

Axis II
: R 46.8 delayed diagnosis of axis II
Axis III : Hypertension
Axis IV : economic problem
Axis V : GAF admission 20-11

PLANNING
MANAGEMENT
Hospitalization
Pharmacotherapy
Psycho-education

PLANNING MANAGEMENT
Hospitalization
Patient is endangered to other people because
patient threatening people around her and damage
around.
The purpose of hospitalization is to decrease the
aggressive symptoms, so patient can handle
herself, and no 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
Pharmacotherapy
O Emergency Room:
Typical antipsychotic
- Inj Haloperidol 5 mg IM
Benzodiazepine
- Inj Diazepam 5 mg IV
O Routine therapy

O Typical antipsychotic

Haloperidol 2 x 5 mg

PLANNING MANAGEMENT
Psycho-education
Educate the patient and family :
Explain to patients family about mental disorder.
There are many factors cause the symptoms,
such as biomoleculers imbalance in the brain,
so we need various aspects for the treatment.
Dont force the patient to understand the family
instead vice versa.
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.
Keep the patient away from objects that can harm
other people and patient.

Thank You