Monday , October

15th,2012
Supervisor :
dr Sabar P Siregar Sp.Kj

Morning
Report

I.Patients Identity
Name : Mr. Am
Age : 28 years old
Gender: Male
Address : Purworejo
Occupation
: Unemployed
Marriage status : Single
Religion : Islam
Last education : S1 ( first semester )
Alloanamnesis
Name : Mr. As
Age : 56 years old
Relation : Patients mother

II.Chief complaint
Patient often agitated
in anger and
emotionally
sensitive.

Presenting illness
One week ago

Patient often gets agitated in anger and easily gets hurt

emotionally.
Patient often destroys and throws things in anger.
Patients is said to hear voices telling taunting him and
asking him to kill someone of random names.
( Patient does not know who the voice is referring to. )
Patient is sensitive and suspects people or even
the guest is in this house talks bad about him.

Patient talks and laughs to himself.

Patient often locks himself in the room.
Patient has difficulty to fall asleep. Said to sleep 2 hours
a day.
Patient often takes a shower each day ( almost 10 times
a day )
Impaired social functions ( He always isolates himself )
Deterioration in performing functioning roles, ability to
care for himself.

HISTORY OF PRESENT
ILLNESS
Psychiatry history
October 2002
was admitted in
RSJ Puri Nirmala
for two weeks.

General medical
history
Hypertension (-)
Head injury (-)
Febrile seizure ( )
History of
asthma ( + )

Drugs and alcohol

abuse history and
smoking history
Alcohol
consumption (-)
Tobacco
consumption (+)
one month ago
drug use (-)

History of Personal Life

PRENATAL

AND PERINATAL HISTORY

His mother was perfectly healthy when she was
pregnant.
Patient delivered through normal delivery at
term by a doctor at the hospital.

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

Mother claims she spent less attention on him after the

arrival of the second child. Patient was 5 at that time.

Cognitive

Sufficient grades and advancement to next level of class.

Late Childhood & Teenage Phase

Sexual development signs & activity

Psychomotor

Begin to have less friends and was a loner. He was placed in a

school outside town alone against his will. (Parents choice )
Begin to lock himself during orientation of new semester as he
was afraid. Unable to face the pressure by seniors during OSPEK.

Emotional

Patient was a very timid person.

Psychosocial

No valid data on when patients puberty. Hair on armpits and

pubis, etc. Had a girlfriend at the age of 17 but of different
religion. Was warned by mother not to continue the relationship.

Patient often keep his feelings to himself.

Communication

Patient has gets easily agitated and do not really talk to people.

Family History

Currently the eldest son in the

family and lives with both parents
at home.
He has two younger brother.
No record of either parentage
having mental disturbance.

Psychosexual history
Patient

psychosexual history was

not assessed.

Socioeconomic
history
Validity

Economic scale: low

Alloanamnesis

: valid

Progression of Ilness
sympto
m

Oktober 2002

Role function

October 2012

 III

Mental State

Appearance :
Young man, appropriate according to age,
dressed appropriately, irritable

State of Consciousness
Clear

Speech:

Quantity : high

Quality

: high

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 : hard to evaluate
Writing and reading skills
: not evaluated
Visuospatial
: not evaluated
Abstract thinking
: not evaluated
Ability to self care
: not 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
: 175/88 mmHg
Pulse rate
: 80x/mnt
Temperature
: afebris
RR:
: 20x/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

Male,
28 years
old
quantitative
Symptoms occured since a week ago
Qualitative
proverty
of spech
Patient
often
gets
agitated
in anger and easily hurt emotionally
Patients
is said
to hear voices
telling
taunting him and

Form
of though
: Non
realistic
asking him to kill someone of random names.
Patient often throws things in anger and slams the door.
Patient talks and laughs to himself.
Patient often locks himself in the room.
Patient has difficulty to fall asleep. Said to sleep 2 hours a day.
Patient often takes a shower each day ( almost 10 times a day )

Behaviour : hyperactive, psychomotor agitation

Attitude : non-cooperative
Mood
: irritable
Affect
: labile
Thought form : Autism
Thought Progress : logorrhea, flight of ideas
Insight : impaired.

Significant Finding Resume

Disability :
Role function: inability to continue
studies after first semester in mass
communication.
Spare time: talks and smiles to himself.
Psychosocial : self isolation, lost
friends
Ability to self care : not good.

Differential Diagnose
F25.0

Schizoaffective Manic type

F20.0 Paranoid Schizophrenia
Disorder

VII.

DIAGNOSTIC
FORMULATION

Axis Multiaxial
I
: F25.0 Schizoaffective
Diagnose Manic
Type
Axis II
: Unknown
Axis III : Past history of asthma
Axis IV : Stopped medication for a month.
Axis V : GAF 30-21

Therapy
medication
Hospitalized
Medication
Initial Therapy:
ER
: - Lodomer 5mg Inj 1 Amp (IM)
: - Inj. Diazepam 1/2 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