CASE OF MORNING REPORT

Sunday, 23 February 2014

Arranged by:
Cherish Idea
Rahmayani
Diva Oktavianita H
Vivien Karina S
Metiel Amigo P
Tri Widianto

Supervisor
dr. Sabar P. Siregar Sp.KJ

Pshychiatry Medical
RSJ Prof. dr. Soerojo Magelang
2014
I. Patients Identity:
Name : Mr. M
Age : 25 years old
Gender : Male
Address : Wonosobo
Occupation : Labourer
Religion : Moslem
Marriage Status : Single
Last Education : Elementary school
II. Alloanamnesis has been done by asking from:
Name : Mr. M
Age : 60 years old
Relationship with patient : Father
III. A. The reason of patient was brought to hospital
Locked him self for 5 years, the health workers take him to hospital
B. Present History
5 years ago (2009)
Patient started to have unusual behavior
He always stay at his bedroom and covered his body with blanket
His father said that he looks like being shame
He always looked down without doing anything
He never talk to his parents except when he got hungry
Sometimes he woke up at midninght and nothing to do
When his friends came, he never want to meet them
Impairment
He didnt work
Poor utilization of leisure time
Social withdrawal
He cant taking care of him self
3 years ago (2011)
His father took him to paranormal for asking about his condition, paranormal
gave the father a sewings and asked him to put in patients wrist, for knowing
about why it could be happen but it didnt work
Patients condition still the same, he just stayed at his bedroom and covered
his body with blanket
He always looked down without doing anything
He never talk to his parents except when he got hungry
Sometimes he woke up at midninght and nothing to do
When his friends came, he never want to meet them
Impairment
He didnt work
Poor utilization of leisure time
Social withdrawal
He cant taking care of him self
Day of admision
He always stay at his bedroom and covered his body with blanket
His father said that he looks like being shame
He always looked down without doing anything
He never talk to his parents except when he got hungry
Sometimes he woke up at midninght and doing nothing
The health workers visited the village and found the condition. Then ask the
parents to take him to RSJS Magelang
Impairment
He didnt work
Poor utilization of leisure time
Social withdrawal
He cant taking care of him self, he didnt take a bath for 5 years
He cant walk, his father must carry him up to move his body
C. History of Illness
1. Psychiatric History :There was no psychiatric history before.
2. General medical history: Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
History of admission (-)
3. Drugs and alcohol abuse history and smoking history: Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (+)
IV. Personal History
A. Prenatal and Perinatal History
Father forgot how gestational age when the child was born
Father forgot how child birth age
B. Early childhood phase (0-3 years old)
Psychomotoric
First time lifting the head (forgot)
Rolling over (forgot)
Sitting (forgot)
Crawling (forgot)
Standing (forgot)
walking-running (forgot)
holding objects in his hand(forgot)
putting everything in his mouth(forgot)
Psychosocial
His father forgot of his childs development :
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
His father forgot when the patient started saying words 1 year like mom
or dad. (6-9 months)
Emotion
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. (the father forgot about it)
Cognitive
There were no valid data on which age the patient can follow objects,
recognizing his father and father, recognize his family members. (the father
forgot about it)
There were no valid data on when the patient first copied sounds that were
heard, or understanding simple orders. (the father forgot about it)



C. Intermediate childhood (3-11 years old)
Psychomotor
No valid data on when patients first time playing hide and seek or if
patient ever involved in any kind of sports. (the father forgot about it)
Psychosocial
No valid data on patient interaction with his surrounding, no valid data on
when patient first entered primary school, on how well patient handle
separation from parent, how well he play with his new friend on first day
school. (the father forgot about it)
Communication
(the father forgot about it)
Emotional
No valid data on patients adaptation under stress, any incidents of
bedwetting were not known. (the patient never told about his life to his
family)
Cognitive
He stopped school in third grade of elementary without any reason
D. Late childhood & teenage phase
Sexual development signs & activity
No valid data on patients first experiece of wetdream (forgot)
Psychomotor
Patient had any favourite hobbies or games, if patients involved in any
kind of sport (forgot)
Psychosocial
Patient had a good relationship with all of his friends
Emotional
No valid data on patients reaction on playing, scared, showed jealously or
competitiveness
Communication
He has good communication with his parents
E. Adulthood
Educational History
On elementary school he didnt continue his study, thre is no reason
Occupational history
He worked as a labourer and a good worker
Marital Status
Single (he never told his fathers about his love life)
Criminal History
No
Social Activity
Before he got the dissorder, he has a good relationship with family and
friends
Current Situation
He lives with his father and father
F. 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
G. Family History
GENOGRAM

H. Psychosexual History
Difficult to assessed
No partner for now
I. Socio-economic history
Economic scale: low
J. Validity
Alloanamnesis : valid
Autoanamnesis : no valid






K. Progression of Disorder

V. Mental State (Sunday, 23
rd
February 2014)
A. Appearance
A male, appropriate to his age, completely clothed, smells bad
B. State of Consciousness
Stupor
C. Speech
Quantity : decreased
Quality : cant be assessed
D. Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Mannerism
Automatism
Bizarre
Command automatism
Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
E. Attitude
Cooperative
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excitement
F. Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed
Affect
Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile
G. Disturbance of perception
Hallucination
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Cant be assesed
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Cant be assessed
H. 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
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia
Cant be assessed
I. Content of thought
Idea of Reference
Idea of Guilt
Preoccupation
Obsession
Phobia
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hipochondry
Delusion of magic-mystic
Delusion of grandiose
Delusion of Control
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of Suspicious
Thought of Echo
Thought of Insertion/withdrawal
Thought of Broadcasting
Cant be assessed
J. Form of thought
Realistic
Non Realistic
Dereistic
Autistic
Cant be assessed
K. Sensorium and Cognition
Level of education : cant be assessed
Orientation of time : cant be assessed
Orientations of place : cant be assessed
Orientations of peoples : cant be assessed
Orientations of situation : cant be assessed
Working/short/long memory: Not cooperative
Writing and reading skills : Not cooperative
Visuospatial : Not cooperative
Abstract thinking : Not cooperative
Ability to self care : Low
L. Impulse control when examined
Self control: low
Patient response to examiners question: poor
M. Insight
Impaired insight
Intellectual Insight
True Insight
Cant be assessed
VI. Physical Examination
Quantity Consciousnes : Composmentis
GCS : E
4
V
5
M
6

Vital sign: Blood pressure : 120/90mmHg
Pulse rate : 96x/m
Respiratiry Rate : 20x/m
Temperatur : afebris
Head :Normocephali
Anemic conjungtiva -/-, icteric sclera -/-, pupil isocore
Neck :normal, no rigidity, no palpable lymph nodes
Thorax
Inspeksi : IC did not show
Palpasi : normal
Palpasi : normal
Perkusi : Dull
Auskultasi : S 1,2 Sound and normal
Lung
Inspeksi : Enlargement ICS (-), retraction (-),
Palpasi : Sterm fremitus dextra = sinistra
Perkusi : Resonance
Auskultasi : Vesicular sound, wheezing -/-, ronchi-/-
Abdomen
Inspeksi : Flat
Auskultasi : Normal peristaltic, tympany sound
Perkusi : Timpani
Palpasi : Pain (-)
Extremity
Ekstremitas Superior Inferior
Capp refill, <2/<2 <2/<2
Warm acral +/+ +/+

Neurological exam : not examined
VII. Resume of Admission
Symptoms
Always stay at bedroom and covered body with blanket
Looks like being shame
Looked down without doing anything
Never talk except when he got hungry
woke up at midninght and nothing to do

Mental Status
Stupor
Decreased quantity of speech
Hypoactive
Rigid
Mutism
Flat
Non cooperative
Passive negativism
Disability
Has not worked
Has not taking care to his self
Poor utilization of leisure time
Social withdrawal
Cant walk
VIII. Differential Diagnosis
F20.2 Catatonic Schizophrenia
F32.2 Severe depression episode without psychotic symptoms
F32.3 Severe depression episode with psychotic symptoms
IX. Multiaxial Diagnosis
Axis I : F20.2 Catatonic Scizophrenia
Axis II : R46.8 delayed diagnosis of axis II
Axis III : No diagnosis
Axis IV : Unclear
Axis V : GAF admission 30-21
X. Planning Management
Hospitalization
To establish self-care, quality of life, employment, and social relationships
Pharmacotherapy
Psycho-education
XI. Response phase
Emergency department
Emergency Room:
Typical antipsychotic: - Inj Haloperidol 5 mg IM
- Inj Diazepam 10 mg IV
Routine therapy
Typical antipsychotic: Haloperidol 2 x 5 mg
Suggest: - ECT
- Physiotherapy
Psychosocial Therapy
Family-Oriented Therapies