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MORNING REPORT

dr. Sabar Parluhutan Siregar, Sp.KJ


GROUP
• HENDRIAN ADE HARDIANTO
• TABITA NUR AMALINA
PERSONAL INFORMATION
PATIENT IDENTITY RELATIVE IDENTITY
• Name : • Name :
• Age : y.o • Age : y.o
• Gender : • Gender :
• Address : • Address :
• Religion : Moslem • Religion :
• Etnich : Javanese • Occupation :
• Occupation : Unemployment • Relation :
• Education : Junior High School • Intimacy :
• Marital Status : • Long Know :
• Date of Entry : 5 Nov 2017
• Date of Examination : 5 Nov
2017
ANAMNESIS
• History was obtained by auto-anamnesis and
alloanamnesis on October 21st 2017 at
outpatient departement

Chief Complaint
• Patient was brought by his family because
wanderin off by himself and didn’t sleep for 5
days before entering hospital.
ALLO-ANAMNESIS
• Wandering off by himself for 3-5 days
• Didn’t come home
• Didn’t eat, drink & sleep
• Confused what should he do when he come
home
• Talking to himself
• Feels like someone want to hurt him so he scared
to go out
• He saw a big black shadow that want to hurt him
AUTO-ANAMNESIS
• Wandering off by himself for 3-5 days
• Hearing sound that talking about him and ordering
• him to go out from his house
• He didn’t feel calm in his house
• He feels that his father know what was he thinking
• and angry because of it
• He saw a big black shadow that want to hurt him
• He couldn’t sleep because he would see the big
• black shadow
HISTORY OF PAST ILLNESS
• Psychiatry Illness
There’s no history of psychiatry disorder before
• General Medical Illness
There’s no history of high fever, seizure, head
trauma, allergy, other chronic disease (DM,
hypertension, cancer) or other serious illness
which need hospitalized
• Substance Abuse
There’s no history of smoking, alcohol use or
drug abuse
HISTORY OF PERSONAL LIFE
• Prenatal
Her mother was having him when she was 20 y.o.
She doesn’t have ANC because of she was poor
and doesn’t have any immunization during the
pregnancy. There is no disease or abnormality
during the pregnancy and the mother in a healthy
mental condition.
• Perinatal
His mother gives birth at a gestational age with a
normal delivery
EARLY CHILDHOOD PHASE
• Psychomotor
There’s no valid data in patient’s psychomotor aspect, such
as tilting body, supine to prone, crawling, sitting, standing,
walking, holding with his hand, scoop up the object or
pining up the object
• Psychosocial
There’s no valid data in patient’s psychosocial aspect such
as showing intention when seeing object, knowing his
family members or pointing what she want without crying
• Communication
There’s no valid data in patient’s communication aspect
such as bubbling, cooing, making sound without meaning,
telling 2-3 syllables without meaning or calling his family
EARLY CHILDHOOD PHASE
• Emotion
There’s no valid date in patient’s emotion aspect such as happy
when playing, smile while seeing interact object, frightened by
strangers, starting to jealousy or competitiveness with others and
toilet training
• Cognitive
There’s no valid data in patient’s cognitive aspect such as copying
sound that he heard for the first time, understand simple words and
learning the shape/function of objects
• Parenting
Patient was parenting by both parents but dominantly by mother.
He was close to her mother. There’s not know how his mother treat
and parenting her like overprotective or not
There’s no valid data about giving breast milk or formula, how long
it was given or when he was given side dish
INTERMEDIATE CHILDHOOD PHASE
• Psychomotor
There’s no valid data in patient’s psychomotor aspect, such as throwing ball, wearing a cloth by
himself, ride bicycle or involved in any kind of sports
• Psychosocial
There’s no valid data in patient’s psychosocial aspect such as started to implement “initiative vs
guilt” concept by planning activities, making their own choices, accomplishing the task, facing
challenge or keep trying when fail. There’s no valid data about how patient started to implement
“industry vs inferiority” concept by having competitive spirit, responsibility, do teamwork, knowing
a good and bad thongs, studying problem and solving problems
• Communication
There’s no valid data in patient’s communication aspect such as mention her name, age and others,
asking/answer question, expressing an opinion, speaking in sentences, telling story and speaking
clearly enough for strangers to understand
• Emotion
There’s no valid date in patient’s emotion aspect such as showing what she want, knowing her
mistake, crying or happy, if it was appropriate/inappropriate with what he want, showing an
empathy to their friend, describing his feeling or starting to developed negative self image
INTERMEDIATE CHILDHOOD PHASE
• Cognitive
There’s no valid data in patient’s cognitive aspect such as knowing
the function of objects, knowing the synonym/antonym of word, or
grouping some object based on their same characteristic
• Parenting
There is no valid data about how patient’s parents guide him to
learn or when his first time at school he doing by herself or
accompany even waited by his parents. There’s no valid data about
whether the patient is still watering on bed or not, or whether
when eating, he still given by her parents or not
• Progress in School
There’s no valid data how patient’s treat his friend at school, how
patient act and playing at school whether she want to lead her
friend or lead by his friend or how patient giving answer when
teacher asking or patient achievement during schooll
LATE CHILDHOOD PHASE
• Psychomotor
There’s no valid data on psychomotor aspect such as playing the games or
some other sports, riding motorcycle, running, kicking the ball to have a
goal, or bringing some heavy stuffs
• Psychosocial
that’s no valid data about hos patients started o implement “identity vs
role function” concept by starting to dress his own up with his own
clothes. Trying to act rebel to show his identity, brawling to show her
power, or going out with his friends.
• Communication
there’s no valid data on communication aspect, such as expressing his
personal opinion in conversation holding longer conversation, giving on
advice and debate.
There’s no valid data on emotion aspect, such as worrying about grades,
appearence and popularity verbally direct anger, being withdrawn, and
self introspection.
LATE CHILDHOOD PHASE
• Cognitive
there’s no valid data on cognitive aspect such as ability to
identify, formulative, and solve the problems with his
reasoning.
• Progress in school
patients not continuing school after graduate from junior
high school because his parents can’t pay the school bill.
• Parenting
there’s no valid data about how patients parent treat him
such as checking his academy progress, giving atentions to
his achivement at school, guide him to learn giving an
advice for him or traeting him at home.
ADULTHOOD PHASE

• Educational
Patient discontinued his study when he was
junior high school. Never stayed class. Good
school achievement. He has many friends.
• Occupational
Patients had a job as a car washer. patient
claimed didn’t have any problems with his
coworkers. Relationship with colleagues is good.
• Marital status
Patient is unmarried
ADULTHOOD PHASE

• Criminal
Patient has no criminal history
• Social activity
Patient lives at home accompanying her sister who is
mentally retarded, but occasionally the patient goes
out to meet her friends. The patient is easy to get
along with the people around his house and several
times the patient helps his neighbors if they need help.
• Current Situation
Patient live with his parent and a sister
FAMILY HISTORY

• Psychiatry Illness
Grandfather of the patient's mother had the same
mental disorder as the patient
• General Medical Illness
There’s no history of high fever, seizure, head trauma,
allergy, other chronic disease (DM, hypertension,
cancer) or other serious illness which need hospitalized
• Substance Abuse
There’s no history of smoking, alcohol use or drug
abuse
Genogram
PHYSICAL EXAMINATION
A. Conciousness: Compos Mentis
B. Vital Sign
1. Blood preassure
120/80 mmHg, right arm, sitting position, appropriate
cuff size
2. Pulse
86 x/minute, regular, filling and tention enough
3. Temperature
36,5oC, axilla
4. Respiratory rate
16 x/minute, regular, symetric, thoracoabdominal type
• Head
Normocephally (+), trauma (-), deformity (-)
• Eye
Anemic conjungtiva (-), icteric sclera (-), pupillary isochor (-), red eye (-/-)
• Nose
Deformity (-), discharge (-) septal deviation (-) symmetric (+) trauma (-)
inflammation (-) nasal flare (-)
• Ear
Deformity (-), discharge (-) inflammation (-) cerumen (+/+)
• Mouth
Drymouth (-) hyperemic mucous (-) normal teeth (-) T1-T1 muscle paralysis (-)
• Neck
Lymph node enlargement (-) skin decolorization (-) JVP (n) mass (-) scar (-)
• Skin
Cyanotic skin (-) turgor(-)
• Cor
• • I: deformity (-) scar (-) ictus cordis (-)
• • P: ictus cordis is palpable on ICS V linea midclavicula sinistra
• • P: cor enlargement (-)
• • A: s1-s2 regular (+) heart murmur (-) s3 gallop (-)
• Lung
• • I: simetrical movement (+) use of acessory muscles (-) trachea deviation (-)
• • P: tactile fremitus (-) movement (-) pain (-)
• • P: sonor
• • A: vesicular sound (+/+) ronchi (-/-) wheezing (-/-) crepitation (-/-)
• Abdomen
• • I: swelling (-) scar (-) inflammation (-)
• • A: intestinal murmur (n) 1x/minute
• • P: tympanic sound (+) in 13 points, liver span (n) 8 cm, spleen enlargement
• (-)
• • P: Superficial pain (-), deep pain (-) hepar and lien is palpable (-) skin
• turgor (n)
MENTAL STATE EXAMINATION
• Observed on October 21st 2017, at 10.00
General appearance
• a man 29 years old, appropriate to his age, look normoweight, good
self-care/ grooming, wears a complete man’s clothes.

Orientation of:
• People: good
• Time: good
• Place: good
• Situation: good
• Consciousness: clear

Physical Contact
Present/absent, equitable/inequitable, constant/non-constant
BEHAVIOR
• Hypoactive • Automatism • Psychomotor agit
• Hyperactive • Automatism of • Compulsive
command • Ataxia
• Echopraxia
• Bizarre • Mimicry
• Catatonia • Mutism • Aggressive
• Active negativism • Acathysia • Impulsive
• Cataplexy • Tic • Abulla
• Somnambulism
• Stereotypy
• Mannerism
ATTITUDE
• Cooperative • Infantile
• Non cooperative
• Labile
• Indifferent
• Apathy
• Rigid
• Tension • Passive negativism
• Dependent • Stereotype
• Passive • Catalepsy
• Excited • Cerea flexibility
VERBAL
1. Quantity: increase/ normal/ decrease
2. Quality: normal/ decrease
• Mood Affect
• Dysphoric Appropriate
• Depressed Inapproriate
• Eutymic Broad
• Elevated Restrictive
• Euphoria Blunted
• Irritable Flat
• Agitation Labil
PERCEPTIONS
• Hallucination (+) Illusion (-)
• Auditory Auditory
• Visual Visual
• Olfactory Olfactory
• Gustatory Gustatory
• Tactile Tactile
• Somatic Somatic
Depersonalization (-)
Derealization (-)
THOUGHT PROGRESS
THOUGHT CONTENT
• Idea of reference • Delusion of hypochondriac
• Delusion of magic mistic
• Preoccupation • Delusion of grandiose
• Delusion of control
• Obsession • Delusion of religion
• Delusion of influence
• Phobia • Delusion of
passivity
• Fantasy • Delusion of
suspicion
• Delusion of persecution • Idea of suicidal
• Idea of suspicion
• Delusion of reference • Thought of
withdrawal
• Delusion of envious • Thought of
broadcasting
• Thought Form Insight• Impaired insight
Attention connection
• Attention easily attracted,
• Non-realistic •• True
Intelectual insight
insight
able to sustained concentration

• Dereistic
• Autistic
• Dereallistic
• Form at thought
• Illogical thinking
Sensorium and Cognition Impulsive control when examine
• Level of education: low • Self control: enough
• General knowledge: low • Patient respond: enough
• Orientation: good
• Working/short/long memory: enough
• Ability to read and write: enough
• Ability of thought: enough
• Ability of independent: enough
RESUME
ANAMNESIS
• Wandering off by himself for 3-5 days
• Talking to himself
• Feels like someone want to hurt him
• He saw a big black shadow
• Hearing sound that talking about him and
ordering him to go out from his house
• Grandfather of the patient's mother had the same
mental disorder as the patient
MENTAL STATUS

• Behavior: hypoactive
• Mood dysphoric / afect blunted
• Auditory & visual hallucination
• Thought progress remming
• Thought content Delusion of suspicion
• Thought form non realistic
• Intellectual insight
SYNDROM ON PATIENT
SYNDROM ON PATIENT
DIFFERENTIAL DIAGNOSE
Multiaxial Diagnosis
• Axis I F. 20.0 Schizophrenia Paranoid
• Axis II No diagnosis yet
• Axis III No diagnosis yet
• Axis IV problem with “primary support group”
(family )
• Axis V GAF at hospital: GAF Scale 40 - 31
(multiple disabilities in connection with reality &
communication, severe disability in some
functions). GAF at check: GAF Scale 60 - 51
(moderate), moderate disability).
PROBLEMS
Organobiologic Psychologic Social problem
. No specific • Found • Energy: slightly
physical or disease psychological decrease
disorders are found disorders such as • Activism: slightly
that affect the the existence of decrease
patient's mental delusions and • Interest in daily
state. Allegedly hallucinations that living: slightly
there is a result in difficulty decrease
neurotransmitter sleeping, talking • Use of community
imbalance that alone, wandering, service: do not use
requires and like a confused ( he didn’t work,
pharmacotherapy. person that seldom go out)
requires
psychopharmaca
and psychotherapy.
Planning Management
• Hospitalization: Patient was planned to be hospitalized
because difficult to do daily activities and harm for
himself
• In emergency room:
Vital sign
Assessed to entry the ward
Responsive drugs: Haloperidol 5mg (IM)
Diazepam 10mg (IV) slow bolus
• Remission phase:
• Target therapy is 100% remission symtomps
• Psycosocial therapy rehabilitation
Planning Management
• Maintenance therapy:
• Haloperidol tab 2 x 5mg
• And give Trihexyphenidil 2 x 200mg if any EPS symptoms appear
• Recovery phase:
• Patient should obey medication drugs consumption followed by
• register control to psychiatrist
• Family education:
• Explain to patients family about patients disease and treatment
plan
• Ask his family to monitor patients progress and make sure
patients take medication as prescribed, and living with the
patient.
• Point In Patient Prognosis
• Premorbid
• Family history Present Bad
• Marital status Unmarried Bad
• Family Support Present Good
• Economical status Less than normal Bad
• Stressor Present Good
• Premorbid personality None Good
• Morbid
• Age onset Young Bad
• Type of disease Psychotic Bad
• Onset Chronic Bad
• Organic disease None Good
• Response of therapy Response Good
• Drug compliance Obedient Good
• PROGNOSIS
• Ad Vitam : Ad bonam
• Ad Functionam : Dubia ad malam
• Ad Sanationam : Dubia ad malam