:

isor SpKJ
v
r
e
Sup iregar,
ar S
b
a
Dr. S

MORNING
REPORT

Wednesda
y,

April 23rd
2014

Patient Identity

Relatives Identity

Reason patient brought to

emergency room:

Stressor

Still unclear

April 20 2014

Day of Admission

Psychiatric History

Hospitalization History

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 like mumbling (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 his mother, recognize his 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 playing hide and seek
or if patient ever involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data on the patients psychosocial development
Communication
The patient has an easy going personality, according to
his father the patient has got quite a lot of friends.
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 personality patients cognitive.

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)
No data on when patients wet dream 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 valid data on the patients psychosocial development
Emotional (NO VALID DATA)
No valid data on patients reaction on playing, scared, showed
jealously or competitiveness
Communication
The patient had no difficulty to communicate with the family
and friends, he was quite open about his problems to his
brother and his parents.

ADULTHOOD

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

Family History
0 Patient is the 1st child out of 2

siblings.

0 Psychiatry history in the family (-)

GENOGRAM

Suffers from
mental illness
Female
Male

Psychosexual History

Progression of Disorder
Sympto
m

4 years
ago

Role
function

2 years
ago

now

Mental State
April 20 2014

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

Noncooperative
Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Emotion

Disturbance of perception

Depersonalization (-)

Derealization (-)

Thought progression

Content of thought

Delusion of grandiose

Idea of Reference

Delusion of Control

Idea of Guilt

Delusion of Influence

Preoccupation

Delusion of Passivity

Obsession

Delusion of Perception

Phobia

Delusion of Suspicious

Delusion of Persecution

Thought of Echo

Delusion of Reference

Thought of Insertion &

Delusion of Envious

Delusion of Hipochondry

Thought of Broadcasting

Delusion of magic-mystic

Can not be assessed

withdrawal

Form of thought
Realistic
Non Realistic
Derealistic
Autism

Sensorium and Cognition

Level of education
: Junior high school
General knowledge
: cant be assessed
Orientation of time
: bad
Orientations of place
: bad
Orientations of peoples : bad
Orientations of situation : bad
Working/short/long memory: cant be
assessed
Writing and reading skills
: cant be
assessed
Visuospatial
: cant be assessed
Abstract thinking
: cant be assessed
Ability to self care
: bad

Physical Status
Consciousnes

: compos mentis

Vital

sign :
Blood pressure
mmHg
Pulse rate
Temperature
RR

: 100/60
:
:
:

88x/mnt
Afebris
22x/mnt

Head

: normocephali, mouth deviation (-)

Eyes

: anemic conjungtiva (-/-), icteric sclera (-/-), pupil

isocore

Neck

Thorax:
Cor

: normal, no rigidity, no palpable lymph nodes

: S 1,2 regular

Lung

: vesicular sound, wheezing -/-, ronchi-/- 5

5
Abdomen : Pain (-) , normal peristaltic, tympany sound
5
5

Extremity : Warm acral, capp refill <2, motoric strength

Neurological exam : not examined

Mental
Status

Impairment

Differential Diagnosis
F20.2 Catatonic Schizophrenia
F25.0 Schizoaffective Manic Type

Multiaxial Diagnosis
Axis I

Axis
Axis
Axis
Axis

: F20.2 Catatonic Schizophrenia

Z91.1 Medicine non
compliance
II
: extrovert
III
: no diagnosis
IV
: unclear
V
: GAF admission 20-11

Problem related to the

patient

PLANNING MANAGEMENT
Inpatient (hospitalization)
0 Behaviour: hyperactive, aggressive, active negativism
0 Attitude:non-cooperative, distrust
0 Mood : Agitation, affect : appropriate
0 Thought progress: Logorrhea, Flight of ideas& loosening of

association

RESPONSE PHASE
Target therapy : 50% decrease of symptoms

(sudden rampage ,talking gibberish,restless,hyperactive,aggressive,

non-cooperative, flight of ideas& loosening of association

Emergency department
Antipsychotics :
Inj. Haloperidol 5mg IM
Diazepam 1 amp IV
Plan of Therapy
ECT
Antipsychotic : Haloperidol 2x2 mg
Re-assess patient

REMISSION PHASE
Target therapy :
100% remission of symptom (sudden rampage
,talking gibberish, restless,hyperactive,aggressive,
non-coperative,flight of ideas& loosening of
association )
Inpatient management
1. Continue the pharmacotherapy
2. Improving the patient quality of life by doing social
vocational skills training such learn good hygiene,
prepare meals and have better communication.
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

RECOVERY PHASE

Target therapy : 100% remission of symptom within 1

year.

THANK YO
U