Friday , October

12th,2012
Supervisor :
dr Sabar P Siregar Sp.Kj

Morning
Report

I.Patients Identity
Name : Miss Y.
Age : 23 years old
Gender: Female
Address : Magelang
Occupation
: Unemployed
Marriage status : Single
Religion : Islam
Last education : Senior High School
Alloanamnesis
Name : Mr. H.
Age : 61 years old
Relation : Patients father

II.Chief complaint
Patient agitated in
anger and kept
scolding family
members.

Presenting illness
10 days ago Patient often gets agitated in anger and starts scolding
family members.
Patient often throws things in anger and slams the
door.
Patient talks and laughs to herself.
At times, patient cries for no reason
Patient often locks herself in the room.
Patient walks out of her house especially late at night.
Impaired social functions ( always isolates herself )
Deterioration in performing functioning roles, ability to
care for herself.

HISTORY OF PRESENT
ILLNESS
Psychiatry history

General medical
history

March 2010 was

admitted in RSJ
Magelang for a
month.

Hypertension (-)
Head injury (-)
Febrile seizure ( )

Drugs and alcohol

abuse history and
smoking history
Alcohol
consumption (-)
Tobacco
consumption (-)
drug use (-)

History of Personal Life

PRENATAL

AND PERINATAL HISTORY

Her mother was perfectly healthy when shes
pregnant.
Patient delivered through normal delivery at
term by a midwife

Early Childhood Phase (0-3 Years Old)

(Continue)
Psychomotoric

Normal growth and development but not enough

information was gathered.

Psychosocial

Was not asked.

Communication
The timing for the patients first words were not known.

Emotion

Patient showed normal reaction when playing,

frightened by strangers and toilet training.

Cognitive

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 y.o)

Psychomotor

No valid data on when patients first time riding a tricycle or

bicycle, if patient ever involved in any kind of sports.

Psychosocial

There were no data on patients gender identification,

Communication

Patient had many friends and socialized well.

Emotional

No valid data on patients adaptation under stress

Cognitive

Sufficient grades and advancement to next level of class.

Late Childhood & Teenage Phase

Sexual development signs & activity

Psychomotor

Begin to have less friends after her illness in SMA II

Emotional

Patient was an active scout and a leader.

Psychosocial

No valid data on when patients puberty. Hair on

armpits and pubis, etc

Patient expressed her feelings widely.

Communication

Patient has communication well with other people

though at times gets easily agitated.

Family History

Currently the third daughter in the

family and lives with both parents
at home.
She has two elder sisters and a
younger brother.
Her fraternal grandmother was said
to have mental disturbance but of
unknown cause.

Psychosexual history
Patient

psychosexual history was

not assessed.

Socioeconomic
history
Validity

Economic scale: low

Alloanamnesis

: valid

Progression of Ilness
sympto
m

Feb 2010

Role function

March 2010

October 2012

 III

Mental State

Appearance :

Young

woman,

appropriate

according

to

age,

dressed appropriately, with black stains on her

pants.
State of Consciousness

Clear

Speech:

Quantity : low

Quality

: poor

Behaviour

Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism

Command automatism
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
Stereotypy
Catalepsy
Cerea flexibility

Emotion
Mood

Dysphoric
Euphoria
Elevated
Expansive
Irritable
Cant be assesed

Affect

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of perception

Hallucinatio
n

Auditory
Visual
Olfactory
Gustatory
Tactile
Somatic

Unable to be
assessed

Depersonalisation (-)

Illusion

Auditory
Visual
Olfactory
Gustatory
Tactile
Somatic

Unable to be
assessed

Derealisation (-)

Thinking
thought progression
Quantity

Logorrhea
Blocking
Remming
Mutisme
Talk active

Quality

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

Thought Process
content of thought

Idea of reference

Preokupasi

Obsesi

Fobia

Delution of persecution

Delution of suspicious

Delution of envious

Delution of hipokondri

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

Unable to be assessed

Thought form
Form

of Thought

Realistic
Non Realistic
Dereistic

Autism

SENSORIUM and cognition

Level of education : enough

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

Impulse
control
when
examined

Insight

Self control : not

enough
Patient response to
examiners question:
Not enough

Impaired insight
Intelectual Insight
True Insight

IV. PHYSICAL EXAMINATION

Internal Status
Conciousness
Vital

: compos mentis

sign:

Blood pressure
: 120/70 mmHg
Pulse rate
: 82x/mnt
Temperature
: afebris
RR:
: 22x/mnt

Head : normocephali

Eyes

: anemic conjungtiva -/-, icterik sclera

-/-, pupil isocore

Neck

: normal, no rigidity,

Thorax:
Chor : unable to assess
Lung : unable to assess

Abdomen : unable to assess

Extremity : Warm acral, capp refill <2

Neurological status
Motoric

: not tested
Physiological reflex
: not tested
Pathological reflex
: not tested

SIGNIFICANT FINDING RESUME

Though progression

quantitative

Female,
23 years
old
Symptoms
occured
since
10 days ago
Qualitative
proverty
of spech
Patient
often gets agitated
in anger and starts scolding

Form of though
: Non realistic
family members.
Patient often throws things in anger and slams the door.
Patient talks and laughs to herself.
At times, patient cries for no reason
Patient often locks herself in the room.

Behaviour : hyperactive, active negativism

Attitude : non-cooperative
Mood
: irritable
Affect
: appropriate
Thought form : Autism
Thought Progress : remming, poverty of speech
Insight : impaired.

Significant Finding Resume

Disability :
Role function: inability to continue
studies after SMA II
Spare time: wandering around, smiles
to herself
Psychosocial : self isolation, lost
friends
Ability to self care : good grooming

Differential Diagnose
F

20.0 Paranoid Schizophrenia

Disorder
F 20.3 Schizophrenia Undifferentiated

VII.

DIAGNOSTIC
FORMULATION

Axis Multiaxial
I
: F20.3 Schizophrenia
Diagnose
Undifferentiated
Axis II
: unknown
Axis III : No concomitant medical condition
Axis IV : Jealousy that younger brother
started working.
Axis V : GAF 30-21

Therapy
medication
Hospitalized
Medication
Initial Therapy:
ER
: - Lodomer 5mg Inj 1 Amp (IM)
: - Inj. Diazepam Amp ( IM )
Ward
: - Tab Risperidon 2x 2mg (oral)

Therapy
Hospitalized
Family education
Explainto her familyabout this patient
mental disorder
Describes stepsoftreatment
Family must maintain the patients drugs
consumption and routine doctor consultation,
so it will increase the efficacy of treatment
Family must keep in touch with patient
intensively, so the patient will not feel lonely.

PROGNOSIS
Ad

vitam
: Ad Bonam
Ad functionum : Dubia
Ad sanationum
: dubia

Thank you