MORNING

REPORT
Saturday, 21st of March
2015
Evening shift
Supervisor:
dr. Sabar P. Siregar, SpKJ

PATIENTS IDENTITY
Name

: Mrs. TYT

Age

: 28 years old

Gender

: Female

Address

: Purwokerto

Occupation : Unemployed
Marriage Status : Married
Religion
Last Education

: Moslem
: D3

GUARDIAN IDENTITY
Alloanamnesis was conducted to:
Name
Age
Sex
Address
Job

: Mr. B
: 59 years old
: Male
: Purwokerto
: Teacher

Marital status : Married

Ethnicity
: Javanese
Relation

: Father

THE REASON PATIENT

WAS BROUGHT TO THE
HOSPITAL
Patient was brought to the hospital by her
father because he was rampage, full with
anger with no reason, and threw things
since 6 years ago.

STRESSOR
Being raped by her boyfriend that soon to
be her husband at 2013.
Being lied by her husband that her
husband has been married and already
have three children at 2014, because of
that they dont live together anymore.

PROGRESSION OF
ILLNESS

2009 (6 YEARS AGO)

Patient cant continued her formal education to bachelors
degree because there was no education program that
supported it. Since that time, patient began to angry easily,
rampage if her demand not fulfilled, threw things because
patient didnt feel comfortable with the noisy voices that
disturbed her when she was alone, awake, or totally arousal,
and saw her aunt shadow that had been passed away.
Patient can ate, took a bath without any command, difficult
to fell asleep because of that noisy voices, shut herself in
her home, didnt interact with others, but patient had
interest in learning English by attending english course.
Then, patient was brought to the psychiatrist, she was given
medicine and
she was controlled routinely to the
psychiatrist. According to her mother, patient was only took
medicine at night because she didnt like feel sleepy all day
long.

2010-2012

Patient always got angry if her demand was not

fulfilled, threw things, rampage, heard noisy voices
frequently that disturbed her when she was alone or
being together with her family, saw her aunt shadow
that has been passed away..
Patient can ate and took a bath by herself, difficult
to fell asleep because of that disrupting voices in
her ears, shut her self in her home, and didnt
interact with her neighbors.
Patient still took her medication and controlled to
the psychiatrist routinely.

2013

Patient always got angry if her demand was not

fulfilled, threw things, rampage, heard noisy
voices frequently that disturbed her when she was
alone or being together with her family, saw her
aunt shadow that has been passed away.
Patient said that her boyfriend brought her to the
hotel, they did sexual intercourse without her
consent. It was happened frequently. After that,
she got pregnant before married.
Patient can ate and took a bath by herself,
difficult to fell asleep because of that disrupting
voices in her ears, shut her self in her home, and
didnt interact with her neighbors.

2014
Patient got married at January 2014, when she was 12 weeks
pregnancy, but then she knew that her boyfriend already married
and had 3 children. She was disappointed with her boyfriend then
they didnt live together anymore
Patient always got angry if her demand was not fulfilled, threw
things, rampage, heard noisy voices frequently that disturbed her
when she was alone or being together with her family, saw her
aunt shadow that has been passed away.
Patient was afraid with her sister because her sister always hit
her when she was pregnant.
Patient ate, took a bath without any command, patient was
difficult to fell asleep because of that disrupting voices in her
ears, shut her self in her home, and didnt interact with her
neighbors.
. Because her condition became worse, she was hospitalized for 1
weeks in RSUD Banyumas. After that, she always controlled to the
psychiatrist routinely and took the medicine regularly.

AUGUST 2014 (8 MONTHS

BEFORE ADMISSION)
Patient gave birth a baby boy with cesarean section. She cant
produce any breast milk, so the baby was given baby formula. The
symptoms still appeared but still the same, such as got angry easily
when her demand didnt fulfilled, threw things, heard voice with no
source, saw her aunt shadow, and asking for unimportant stuffs (like
as bought 1 clothes a day, want to have a car). Her shopping
behavior became worse day by day.
Patient felt that her neighbor can read her mind, she was being
controlled by other person outside, she also said that the news in TV
broadcasted her mind, and when she watched TV news about jail,
she felt like the polices wanted to arrest her and be on the shelf.
Patient ate and took a bath without any command, difficult to fell a
sleep, cant take care of her son, just stayed at home, didnt want to
interact with others, like for playing her gadget, and watching TV
all day long.

SEPTEMBER 2014-FEBRUARY
2015

Patient was rampage, got angry easily,..

Patient heard a noisy voices from a man and
woman that asked Angkat tangan lo
frequently when she was awake, began to sleep,
or being alone. The voices was threatened her.
She also heard voice that seduced her. Patient
saw her aunt shadow that had been passed
away.
Patient felt that her neighbor can read her
mind, she was being controlled by other person
outside, she also said that the news in TV
broadcasted her mind, and when she watched
TV news about jail, she felt like the polices
wanted to catch her and brought her to the jail.

CONT..(SEPTEMBER 2014FEBRUARY 2015)

Patient ate and took a bath without any

command, difficult to fell a sleep, just stayed at
home, cant take care of her son, didnt want to
interact with others, like for playing her
gadget, and watching TV all day long. Patient
have an interest in learning Mandarin
language, so she took the Mandarin course.
Patient still took her medication and controlled
to the psychiatrist routinely.

1 DAY BEFORE ADMISSION

Patient was rampage, got angry easily, and threw the

powder bottle away because her son was crying asked
for milk.
Patient threw stones to her neighbor house because she
felt disrupted.
Patient heard a noisy voices from a man and woman that
asked Angkat tangan lo or seduced her frequently
when she was awake, began to sleep, or being alone. The
voices was threatened her.
Sometimes, patient saw her aunt shadow that had been
passed away.
Patient felt that her neighbor can read her mind, she was
being controlled by other person outside.
She also said that the news in TV broadcasted her mind,
and when she watched TV news about jail, she felt like
the polices wanted to catch her and brought her to the

CONT.. (1 DAY BEFORE

ADMISSION)

Patient ate and took a bath without any

command, difficult to fell a sleep, just stayed at
home, cant take care of her son, didnt want to
interact with others, like for playing her
gadget, and watching TV all day long.
Patient still took her medication, but it didnt
help anymore.

HISTORY OF PAST ILLNESS

Psychiatric Illness
Patient has a history of psychiatry illness.
Patient was hospitalized in RSUD Banyumas at
2014 for one week.
General Medical Illness
Patient has no general medical illness
Substance Abuse
Smoking (-), alcohol (-), NAPZA (-)

FAMILY HISTORY
There is no history of psychiatric illness in his family

GENOGRAM
Male
Female
Patient
Living
together
Died

PROGRESSION OF ILLNESS
Symptom

2009

Role of Function

2013

2014

March
2015

HISTORY OF PERSONAL LIFE

1. Prenatal and Perinatal History
2. Early Childhood Phase
3. Intermediate Childhood
4. Late Childhood

PRENATAL AND PERINATAL

The patient was born with bidan,

normal
deliveries,
an
expected
pregnancy, and her condition right after
she was delivered

DEVELOPMENTAL HISTORY (GROSS MOTORIC)

Ability
Elevating the head
Moving to supine position on
its own
Sitting
Standing
Walking
Climbing up the ladder
Standing 1 foot/jump

Result
Unidentifi
ed
Unidentifi
ed
Unidentifi
ed
Unidentifi
ed
Unidentifi
ed
Unidentifi
ed
Unidentifi

Normal Range
0-3 months
3-6 months
6-9 months
9-12 months
12-24 months
24-36 months
36-48 months

DEVELOPMENTAL HISTORY (FINE MOTORIC)

Ability
Holding a pencil
Holding 2 objects at the
same time
Piling 2 cubes
Inserting objects into
container
Rolling a ball
Doodling
Wearing shirt

Result
Unidentifie
d
Unidentifie
d
Unidentifie
d
Unidentifie
d
Unidentifie
d
Unidentifie
d
Unidentifie

Normal Range
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24-36 months
36-48 months

DEVELOPMENTAL HISTORY (LANGUAGE)

Ability
Oooh-aah
Turning toward the sound
High-pitched sound
Voice without meaning
(mamama, bababa)
Calling 2-3 syllables without
meaning
Calling 3-6 words that have
meaning
Talking at least with two

Result
Normal range
Unidentifie
0-3 months
d
Unidentifie
3-5 months
d
Unidentifie
3-6 months
d
Unidentifie
6-9 months
d
Unidentifie
9-12 months
d
Unidentifie
18-24 months
d
Unidentifie
24-36 months

DEVELOPMENTAL HISTORY (SOCIAL & PERSONAL)

Ability
Know their mother
Reach out
Clap
Playing peek a boo
Know their family
Appoint what he wants
without crying or whining
Tidy up toys

Result
Normal range
Unidentifie
0-3 months
d
Unidentifie
3-6 months
d
Unidentifie
6-9 months
d
Unidentifie
6-9 months
d
Unidentifie
9-12 months
d
Unidentifie
12-18
d
months
Unidentifie
24-36
d
months

HISTORY OF PERSONAL LIFE

Prenatal and perinatal

Patient was wanted and planned by her parents.
Patients mother was 27 years old during
pregnancy and labor, and had no illness
Patient was delivered by normal labor, and by
traditional birth attendants
Patient consumed pure breast milk for 6 months

HISTORY OF PERSONAL LIFE

Early childhood phase (0-3 years old)

Psychomotor
There was no valid data in patients psychomotor aspect (such as tilting the
body, supine to prone, sitting, standing, walking, smiling, holding her own
hand, scoop up object, holding pencil and pilling up two objects)
Psychosocial
There was no valid data in patients psychosocial aspect (such as replying to
smile, smiling when seeing interesting object, playing cilukba, knowing her
family members and pointing what she wanted without crying)
Communication
There was no valid data in patients communication aspect (such as
bubbling, cooing, making sounds without meaning, telling 2-3 syllables
without meaning and calling mama/papa)
Emotion
There no valid data in patients emotion aspect (such as when patient
playing, frightened by strangers, starting to show jealousy or
competitiveness towards other, and toilet training)
Patient didnt pee or defecate in her pants when she was two years old
Cognitive
There was no valid data in patients cognitive aspect (such as copying

HISTORY OF PERSONAL LIFE

Intermediate childhood phase (3-11 years old)
Psychomotor
There is no valid data on when patients first time playing hide and seek
or if patient ever involved in any kind of sports.
Psychosocial
There was no valid data in patients psychosocial data (such as developing
initiative capacity, seeking for socialization, starting social interaction with
others, developing self worth in owns abilities and competitive capacity).
Communication
There is no valid data on patients communication data (ability to
communicate with same age friends/peers, and express needs and wants).
Emotion
There is no valid data on patients emotion data (such as ability to
experience physiologic response due to emotion)
Cognitive
Patient went to elementary school at 6 years old. And she could follow all
her school program and study properly.

HISTORY OF PERSONAL LIFE

Late childhood and teenage phase (11-18 years old)
Psychomotor
There is no valid data on patients psychomotor data (such as
favorite activities or games, if patient involved in any kind of sports).
Psychosocial
Patient was an introvert person and she always choose for her
friends.
Communication
There is no valid data in patients communication data (ability to
interact with peers others, ability to discuss subjects and question,
tolerate opposite opinions)
Emotion
There is no valid data in patients emotion data (ability to control
physiologic response due to emotion; such as palpitation, increased
sweating when angry)
Cognitive
Patient graduated from her senior high school.

HISTORY OF PERSONAL LIFE

Adulthood phase (18 years old-now)

Educational
Patient finished her senior high school and continue her education to college
as an secretary and graduated as D3 with cum laude. Patient has interest
in learning the other language as English and Mandarin.
Occupational
Not employee
Marital status
Patient was siri marriage at 2014, but then they didnt live together.
Patient has 1 son who is 8 months old. Patient cant produce breast milk, so
her son was given baby formula.
Criminal
She has no criminal history
Current situation

ERIKSONS STAGES OF PSYCHOSOCIAL

DEVELOPMENT
Stage
Infancy (birth to 18
months)
Early childhood (23 years)
Preschool (3-5
years)
School age (6-11
years)
Adolescence (12-18
years)
Young adulthood
(19-40 years)

Basic Conflict
Trust vs mistrust

Important
Events
Feeding

Autonomy vs shame Toilet training

and doubt
Initiative vs guilt
Exploration
Industry vs
inferiority
Identity vs role
confusion
Intimacy vs
isolation

School
Social
relationships
Relationship

MENTAL STATE
(MARCH 21ST 2015)
Appearance
A female, appropriate for his age, wear complete clothes,
good self grooming,
State of Consciousness
Neurological: Clear (compos mentis)
Psychological: Unclear
Social: Impaired
Speech
Quantity : Decrease
Quality : Decrease

Behaviour
Hypoactive
Hyperactive
Echopraxia
Catatonia
Negativism
Cataplexy
Stereotipy
Mannerism
Automatism
Command
automatism
Bizarre

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

Tremor
Floxilation
Anergy
Dischynesia
Muscle rigidity
Bradychynesia
Khorea
Convulsion
Dystonia
Aminia

DISTURBANCE OF PERCEPTION

Depersonalisation (-)

Derealisation (-)

THOUGHT PROGRESSION

CONTENT OF THOUGHT
Idea

of reference
Preoccupation
Obsession
Phobia
Delusion of
persecution
Delusion of reference
Delusion of envious
Delusion of hipochondry
Delusion of magicmystic

Delusion of grandiose
Delusion of control
Delusion of influence
Delusion of passivity
Delusion of perception
Thought echo
Thought insertion
Thought withdrawal
Thought broadcasting
Cant be assessed

FORM OF THOUGHT
Realistic
Non Realistic
Dereistic
Autistic

SENSORIUM AND COGNITION

Level of education
: Good
General knowledge
: Good
Orientation of T/P/P/S
: Good
Working/short/long memory : Good
Writing and reading skills : Good
Ability to self care
: Good

ORIENTATION
Orientation T/P/P/S :Good/Good/Good/Good

EXAMINATION
March 21st , 2015

PHYSICAL EXAMINATION
Conciousness:
Vital

Compos mentis

Sign:
Blood pressure : 100/60 mmHg
Pulse rate
: 75x/min
Temperature
: 36,5oC
Respiration rate : 19x/min

GENERALIST STATE
a. Head:
Normocephali, mouth deviation (-)
Anemic conjungtiva (-/-), icteric sclera (-/-), pupil
isocore
b. Neck: Normal, no rigidity, no palpable lymph
nodes, meningeal sign (-)
c. Thorax:
Cor: S1-S2 regular, murmur (-), gallop (-)
Pulmo: Vesicular sound +/+, wheezing -/-, ronchi
-/d. Abdomen:
Flat, abdominal wall//chest wall, normal peristaltic,
tympany sound, tenderness (-), mass (-), liver,
spleen, and kidney not palpable

NEUROGICAL EXAMINATION
Cranial nerves examination:
CN I

: cant be assessed

CN II

: cant be assessed

CN III, IV, VI
CN V

: cant be assessed

: cant be assessed

CN VII : cant be assessed

CN VIII : cant be assessed
CN IX : cant be assessed
CN X

: cant be assessed

CN XI : cant be assessed
CN XII : cant be assessed

Physiological Reflex
Upper extremities: Biceps reflex, triceps reflex, brachioradial :
cant be assessed
Lower extremities: Patella reflex, achilles tendon reflex : cant
be assessed
Pathological Reflex
Upper extremities: Hoffman, tromner : cant be assessed
Lower extremities: Babinski, chaddok, gordon, oppenheim:
cant be assessed
Motoric Examination

RESUME
RESUME

A woman, 28 years old, married, unemployed, change in

behavior : rampage, got angry easily, threw things
Symptom:
Mental Status:
Impairment:
Patient rampage, got angry
easily, threw things.
Patient threw stones to her
neighbor house because she felt
disrupted.
Patient heard a threatened noisy
voices from a man and woman
that asked Angkat tangan lo or
seduced her frequently when she
was awake, began to sleep, or
being alone.
Patient saw her aunt shadow
that had been passed away.
Patient felt that her neighbor can
read her mind, she was being
controlled by other person
outside, her mind was being
broadcasted in the TV news, and
when she watched TV news
about jail, she felt like the
polices wanted to catch her and

Behavior:
Hypoactive
Attitude : Noncooperative,
infantile
Mood : Dysphoria
Affect :
Inappropriate,
blunted
Perception :
hallucination
auditory (+).
Visual(+)
Progression of
Thought:
remming, slow of
speech
Content of thought
: delusion of
control, thought
broadcasting,

Patient do
less socialize
Patient
difficult to
fell a sleep
Patient cant
take care of
her son

SYNDROME

Delusion of bizzare
Auditory hallucination
Visual hallucination

Schizophrenia
syndrome

Impairment of social interaction and do

her role as mother
Auditory hallucination (command,
threaten)
Thought of broadcasting
Delusion of control
Delusion of persecution
Excessive energy
Excessive shopping
Difficult to sleep

Schizophrenia
Paranoid
Syndrome
Manic
Syndrome

DIFFERENTIAL DIAGNOSIS

F20.0 Paranoid schizophrenia

F25.0 Schizoaffective disorder manic type

MULTIAXIAL DIAGNOSIS

Axis I

: F20.00 Continue Paranoid

Schizophrenia
Axis II
: R 46.8 Delayed diagnosis for Axis II
Axis III
: No diagnosis
Axis IV
: Being lied by her husband
Axis V
: GAF admission 20-11

PATIENTS PROBLEMS

Biological problem
Patient symptoms because of an imbalance in dopamine & serotonin
activity, receptors and sensibility in the post synaptic neuron.

Psychological problems
Problem with her partner

Social problem
She cant socialize well with others

MANAGEMENT
TT

PLANNING MANAGEMENT

 Hospitalization
Patient was hospitalized because she is rampage, throw things
and poor impairement.

MANAGEMENT PLANNING:

Emergency Department
Inj. Haloperidol 5 mg 1 Amp IM
Inj. Diazepam 5 mg 1/2 Amp IV

RESPONSE PHASE

Target Therapy
50% decrease of symptoms
Maintenance Therapy
Haloperidol 2x5mg daily for first 2 weeks whether there
is any hypersensitivity reaction or not Haloperidol
decanoas 50mg/cc, IM every 2-4 weeks (0.5 cc for every 2
weeks in first month, then 1cc every month)
ECT

REMISSION PHASE

Target therapy :
100% remission of symptom in 4-9 months
Inpatient management
Haloperidol tab 2x5 mg daily
Improving the patient quality of life :
Teach patient about her social & environment
(interact with her family, socialize with her
neighbor or friends, find a hobby to do on her
spare time)
Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy

RECOVERY PHASE

Target therapy :
100% remission of symptom in 1 year
Continue the medication, control to psychiatrist
Rehabilitation :
1. Consult to psychologist to help patient finding a
hobby
2. Help patient to interact normally with her family
and neighbor
3. Cognitive behaviour therapy (communication skill,
social interaction skill, coqnitive skill, and academic
skill).

FAMILY EDUCATION

Mental disorders can be controlled by medicines, so

it is important to take the medicines routinely and
patients family must control the medication, control
routinely to the psychiatrist
If the patients family find any sign of overdose or
side effect of the medication, lets bring patient to the
psychiatrist as soon as possible
Give strength and support (Treat patient like you
treat any other people, help patient if he should be
helped, dont push patient to understand the family,
but her family that has to understand her, dont be
too emotional to patient
Check if there is any relapse or recurrence
symptoms ( such as difficult to sleep, less socialize,
self care decrease, etc.)

THANK YOU