MORNING

REPORT
Monday, 9th September 2013

SUPERVISOR
dr. SABAR P. SIREGAR, SP.KJ

I. PATIENTS IDENTITY
Autoanamnesis
Name
Age
Gender
Address
Occupation
Marital status
Last education
(graduated)
Alloanamnesis
Name
Age
Relation

:
:
:
:
:

Mr. A
55 years old
male
Magelang
Putu Seller
: Married
: Junior High School

: Mr. S
: 60 years old
: Patients Brother

THE REASON WHY THE PATIENT

WAS BROUGHT TO HOSPITAL
Raged, wandering
alone

PRESENT HISTORY
2007

2012

Angry without any

reason
Raged
Difficult to sleep
Decreased appetite

want to do household chores,

Social
withdrawal,
good
utilization of leisure time,
good self grooming.

Angry without any

reason
Raged
Talk to herself
Decreased appetite
Difficult to sleep
Wandering alone

Didnt want to do household

chores, Social withdrawal,
poor utilization of leisure
time, good self grooming.

PRESENT HISTORY
3 days
ago

Day of
admission

-Raged
-Angry without any
reason
-Difficult to sleep
-decreased appetite
-Throwing his
neighboors home
with stones
Didnt want to do household
chores, Social withdrawal ,
poor utilization of leisure
time, good self grooming.

-Angry without any

reason
-Wandering alone
-Difficult to sleep
-Decreased appetite
-Disturb his
neighboor

Didnt want to do household

chores, Social withdrawal,
poor utilization of leisure
time, good self grooming.

PAST 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 words 1 year like mom or dad. (69 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

Sexual
development signs & activity (NO VALID DATA)
PHASE
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

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 3th child of 5 siblings.
There was no any history of psychiatric

disorder in her family.

Psychosexual history
Patient

psychosexual
history
is
appropriate of his gender and attracted to
woman.

:Female

: Patient

:Male

: RIP

Live together

PROGRESSION OF DISORDER
Sympto
m

2007

2008

Role function

2009

2011

2012

3 days ago

now

Mental State
(Monday , 9th September 2013)
Appearance :
a man, appropriate according to age, wear complete
clothes, good self grooming
State of Consciousness
Clear
Speech:
Quantity : Increased
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

Disturbance of perception

Depersonalisation (-)

Derealisation (-)

Thinking thought progression

Content of thought
Idea

of Reference

Delusion of grandiose

Preocupation

Delusion of Control

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Delusion

of Persecution

Delusion of Perception

Delusion

of Reference

Delusion of suspicious

Delusion

of Envious

Thought of Echo

Delusion

of Hipokondry

Thought of Insertion/withdrawal

Delusion

of magic-mystic

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
: good

Internal Status
Conciousnes
Vital

: composmentis

sign :

Blood pressure
Pulse rate
Temperature
RR

: 160/90 mmHg
: 94 x/mnt
: afebris
: 20x/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

Differential Diagnose
F20.0 Paranoid Schizophrenia
F25.0 Schizoaffective disorder manic type

Multiaxial Diagnose
Axis I
Axis II
Axis III
Axis IV
Axis V

: F25.0 Schizoaffective disorder manic type

: R46.8 diagnostic delayed axis II
: Stage 2 hypertension (SBP 160 or DBP
100)
: Economic problem (unsold his putu )
: GAF admission 20-11

PLANNING
MANAGEMENT
Hospitalization
Pharmacotherapy
Psycho-education

PLANNING
MANAGEMENT
Hospitalization

Patient is endangered to other people because

patient threatening people around him and
damage around.
The purpose of hospitalization is to decrease the
aggressive symptoms, so patient can handle
himself, and no threatening people around him.
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:
- Inj Diazepam 5 mg IV
- Inj Haloperidol 5 mg IM
O Routine therapy
- Haloperidol 2 x 5 mg
- Captopril 3 x 25 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 chemical 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 he 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