Morning Report

Monday February 16th , 2015

Supervisor:
Dr. Sabar Siregar, Sp. KJ
ADIL HIJRI MUHAMMAD
20090310075
FKIK UMY

Patients Identity
1.
2.
3.
4.
5.
6.
7.
8.

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mr. N
: 33 years old
: male
: Tanggulangi, Kebumen
: Farmer
: married
: Javanese
: Elementary School

Guardian Identity
Alloanamnesis was conducted to :
1.
2.
3.
4.
5.
6.
7.
8.
9.

Name
Age
Sex
Address
Job
Education
Marital status
Ethnicity
Relation

: Mr. M
: 55 years old
: male
: Tanggulangi, Kebumen
: Farmer
: Elementary School
: married
: Javanese
: Father

Reason brought to hospital

Patient was brought by his guardi

an because he rampage and angry

without any reason, then He hit hi
s wife and parents over and over.

Stressor
Unclear

Progression of Illness

Februar
y 2003

Start to looks weird, sometimes

looks afraid without any reason
he begin to listen somebody
whisper to him, threatend and
order him
Sometimes looks suspicious to
other people
His family asking help to orang
pintar to treat him, but his
symptoms just up and down for
years

Progression of Illness

May
2014

Patient often to scream without any

reason, sometimes rampage and
angry, Almost always looks frigthened
all the time
He sure something scary always follow
him, always try to control and influence
him, enter to his mind, and conduct
him to do something horrible such as
rampage, hit someone, etc
He sure everybody know what he is
thinking, and try to threaten him
limited social interaction, poor self
grooming, and sleep disorder (he cant
start to sleep).

Progression ofPatient
Illness
start
3 days
before
patient
s
admissi
on

to rampage and
scream without a reason, He often
hit his wife and his parents. He did
it because a horrible creature, big
and black, always threat him, and
command him to do such things.
That creature control and influence
him, make him become powerless
Odd thinking enter to his mind,
related with that creature, make
him sure he must fight back to
people before they do it
he sure that people arround him
has connection with that creature,
and together try to put him in the
jeopardy
limited social interaction and
activity, poor self grooming, cant
sleep

The day of admission

His guardian cant hold any longer to face his c

ondition and decided to brought him to RSJ So

erojo Magelang.

History of Past Illness

Psychiatric illness

There is no history of pcychiatric illness.

General medical illness
There is no history of high fever, seizure, h
ead trauma, or any other serious illness wh
ich needs hospitalization
Substance abuse
There is no history about alcohol use, drug
abuse or smoking .

Progression of Illness
Symptoms

2003

Role
Function

2014

Feb2015

Family History
There is no history of psychiatric illnes

s in her family.
There is no history of high fever, seizu
re, head trauma, or any other serious il
lness which needs hospitalization

GENOGRAM

History of Personal Life

Prenatal and perinatal
There was no valid data in patients prenat

al and perinatal aspect, such as :

Patients mothers age and condition whe
n she was pregnant
Patients mothers delivery history and pat
ients perinatal condition.
Patients immunization status

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 memb
ers and pointing what she wanted without crying)

Communication
There was no valid data in patients communication aspect (such as bubbling, cooi

ng, making sounds without meaning, telling 2-3 syllables without meaning and ca
lling mama/papa)

Emotion
There no valid data in patients emotion aspect (such as when patient playing, frig

htened 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 sounds that

she heard for the first time and understanding simple orders)

History of Personal Life

Intermediate childhood phase (3-11 years old)
Psychomotor

No valid data on when patients first time playing hide and s

eek or if patient ever involved in any kind of sports.

Psychosocial
No valid data

Communication
No valid data

Emotion
No valid data

Cognitive
No valid data.

History of Personal Life

Late childhood and teenage phase (11-18 years old)
Psychomotor

No valid data if patient had any favorite hobbies or games, if

patient involved in any kind of sports.

Psychosocial

No valid data
Communication
No valid data

Emotion
No valid data

Cognitive
After graduating from elementary school, patient did not go

to school anymore

History of Personal Life

Adulthood phase (18 years old-now)
Educational
Patient graduated from elementary school

Occupational
Patient had housewife.

Marital status
Patient has got married.

Criminal

She has no criminal history

Social activity

Patient was a resident of pondok pesantren and sometimes i

nterated with other resident.

Current situation

Patient live alone.

Eriksons stages of psychosocial development

Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

Autonomy vs shame
and doubt

Toilet training

Initiative vs guilt

Exploration

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

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)
Preschool
(3-5 years)
School age
(6-11 years)

Maturity
(65- death)

Examination
Morning Report
Monday February 16th , 2015

Physical Examination
Morning Report

General physical examination

General appearance :
he looks in good status

Vital sign
:
BP : 120/70 mmHg
HR : 100x/m
to : afebris
RR : 20x/m

General physical examination

Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax
Cor

Lung

:
: S1 S2 regular, murmur -, gallop
: vesicular sound +/+, wheezing -/-, ronchi-/-

Abdomen

flat, abdominal wall//chest wall, normal peristaltic, tympany sound, t

enderness -, mass -, liver, spleen and kidney not papable

Extremity

: Warm acral, capp refill <2, edema (-)

Neurological examination
Level of Consciousness :
compos mentis, E4V5M6 (15)

General Appearance :
Body posture : normal
Abnormal movement : Walking style : normal

Neurological examination
Cranial nerves examination:
CN I
CN II

: in normal finding
: in normal finding
CN III,IV,VI
: in normal finding
CN V
: in normal finding
CN VII
: in normal finding
CN VIII
: in normal finding
CN IX
: in normal finding
CN X
: in normal finding
CN XI
: in normal finding
CN XII
: in normal finding

Neurological examination
Motoric
Upper extremities: tonus (+), trophy : eutrophic, power of movem

ent : shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve f

unction : 5, ulnar nerve function : 5, median nerve function : 5
Lower extremities: tonus (+), trophy : eutrophic, power of movem
ent : hip joint : 5, knee joint : 5, ankle joint : 5

Sensorium
DCML system : proprioception, fine touch : no abnormalities
AL system : vibration, temperature, crude touch, pain : no abnorm

alities

Neurological examination
Physiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+), brachioradi

al (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological reflex
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski (-), chaddok (-),gordon (-),oppenhei

m (-), rossolimo (-), clonus -/Meningeal sign

Neck stiffness (-), brudzinski neck sign (-), brudzinski contralateral

leg sign (-), kernig sign (-)

Cerebellum function
Adhyadokokinesia (-), romberg test (-), finger to nose test (no ab

normalities), tip to toe walk (no abnormalities)

Mental State Examination

Morning Report
Monday February16th, 2015

General Appearance
A Man, age 33 years old, appropri
ate to his age, tension, and wearin
g bad cloth, poor self grooming

Orientation
Time : good
People : good
Place : good
Situation : good

Consciousness

Clear

Behavior

Hypoactive

Hyperactive

Echopraxia

Catatonia

Active

negativism

Cataplexy

Streotypy

Mannerism

Automatism

Bizzare

Command

automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor

Compulsive

Ataxia

Mimicry

Aggresive

Impulsive

Abulia

agitation

Attitude

Cooperative

Non-cooperative

Indiferrent

Apathy

Tension

Dependent

Passive

Infantile

Labile

Rigid

Passive

negativism

Stereotypy

Catalepsy

Cerea flexibility

Excited

Emotion
Affect

Mood

Dysphoric
Depressed
Euthymic
Elevated
Euphoria
Irritable
Agitation

Inappropria
te

Broad
Restrictive
Blunted
Flat
Labile

Disturbance in Perception
Hallucination

Auditory (+)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)

Illusion

Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Derealization (-)

Progression of Thought
Quantity

Logorrhea
Blocking
Remming
Mutism
Talkative

Quality

Irrelevant answer
Coprolalia
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangentiality
Verbigration
Perseveration
Sound association
Word salad
Echolalia

Content of Thought

Idea of Reference

Delusion of Grandiose

Preoccupation

Delusion of Control

Obsession

Delusion of Religion

Phobia

Delusion of Influence

Fantasy

Delusion of Passivity

Delusion of Persecution

Delusion of Suspicion

Delusion of Reference

Idea of Suspicion

Delusion of Envious

Thought of Echo

Delusion of Hypochondriac

Thought of Insertion

Delusion of Magic-mystic

Thought of withdrawal

Idea of suicidal

Thought of Broadcasting

Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated

Cognitive Function
Level of education

: finished elementary school

General knowledge
: poor
Working/short/long memory: poor
Writing and reading skills : good
Visuospatial
: good
Abstract thinking
: poor
Ability to self care : poor

Impulse Control When Examined

Self control: Enough
Patient response to examiners question: poor

Insight
Impaired insight

(patient did
not know that she is mentally ill)

Intellectual Insight
True Insight

Resume
Morning Report

Patient was brought by his guardian because he rampage and angry without any
reason, then He hit his wife and parents over and over.
Symptom:
Angry and
rampage
without any
reason.
He often hit his
wife and
parents
A horrible
creature
control and
influence him,
make him
became
powerless
Odd thinking
enter to his
mind make him
sure he must
fight back to
people before

Mental Status:

Behavior :
Hyperactive,
psychomotor
agitation
Mood : Disforik
Affect : Blunted
Progression of
Thought:Remming
Hallucination :
Auditory (hearing
sound that threat
and command him)
Visual ( see horrible
big and black
crature)
Content of thought :
tought of insertion,
tought of
broadcasting,
delusion of control,
delusion of influence,
delusion of passivity,

Impairment:
Patient limited
socialize with
others
Patient cant work
Patient cant sleep

Diagnosis
Morning Report

Syndrome
Thought of Broadcasting
Thought of Insertion
Auditorik Halusination

Schizophrenia
syndrome

Visual Halusination
Delusion of Control
Delusion of Passivity
Delusion of influence
Auditory Halusination: Command, Threatend
Delusion of control
Delusion of Passivity
Delusion of influence
Delusion of Suspicion

Schizophrenia
paranoid syndrome

Next...
Psychomotor agitation

Catatonic
syndrome

Differential Diagnosis
F20.0 Paranoid Schizophrenia
F20.2 Catatonic Schizophrenia

Multiaxial Diagnosis
Axis I : F20.0 Paranoid Schizophrenia
Axis II: R46.8 Delayed diagnosis
Axis III
Axis IV
Axis V

: No diagnose
: Stressor unclear
: GAF admission 20-11

Patients problems
Biological problem
Positive symptoms because of an increase in dopa

mine amount in the post synaptic neuron

Psychological problems
unclear

Social problem
She cant socialize well with others

Management
Morning Report

PLANNING MANAGEMENT

Management Planning
Hospitalization
Patient was hospitalized because
Angry and rampage without any reason.
He often hit his wife and parents

Emergency Department
Inj. Haloperidol 5 mg 1 Amp IM
Inj. Diazepam 5 mg 1 Amp IV
Suggest ECT

Response Phase
Target Therapy
50% decrease of symptoms
Maintenance Therapy
Haloperidol tab 5mg 2x1
Suggest ECT

Remission phase
Target therapy :
100% remission of symptom
Inpatient management
Haloperidol tab 5mg 2x1
Improving the patient quality of life :
Teach patient about her social & environment (interact with her fami

ly, socialize with her neighbor or friends, find a hobby to do on her s

pare time)
Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy

Recovery Phase
Continue the medication, control to psychiatrist
Rehabilitation :
Consult to psychologist to help patient finding a h

obby
Help patient to interact normally with her family a
nd neighbor

Family Education
Explain to the family that anyone could have mental disorders
Mental disorders are caused by multifactorial factor, not only

by genetic inheritance
Mental disorders mostly are affected by chemical imbalance i
n brain
Mental disorders can be controlled by medicines, so it is impo
rtant to take the medicines routinely
Treat patient like you treat any other people
Help patient if she should be helped
Dont push patient to understand the family, but her family th
at has to understand her
Dont be too emotional to patient

Thank You!
Monday january 12th , 2015