MORNING

REPORT
Thursday, March 19th 2015
Night shift
Supervisor:
dr. Sabar P. Siregar, Sp. KJ.

Patients Identity

Name
: Mr. S
Age
: 31 years old
Gender : Male
Address
: Tegal Sari, Purworejo
Occupation : Unemployed
Marriage Status : Married
Religion
: Moslem
Last Education
: Elementary School

Alloanamnesis
Guardian Identity
Name : Mr. J
Age
: 40 years old
Relation : Brother in law

The reason patient was

brought to the hospital
Patient was brought to the hospital by his
brother because he was angry and rampage
without any reason. He slamed the door and
window, repeatedly.

Stressor
unclear

Progression of Illness
2013
- Patient has been hospitalized in
RSJ Magelang for one month
because he was angry and
rampage. He destroyed some
households, and was seen talk by
himself when he was alone. After
discharged, patient never take
his medicine and never check his
condition to the doctor.
- Patient still be able to work as
construction workers.

2015 ( one month before

admission)

- Patient started to work in

Jakarta as a workers in
catering bussiness.
- There is no information
whether he had some weird
behaviour just like now.

Three day before admission

The patient seen talk by himself when he was

alone, always daydreaming, sometime he was
crying without any reason in the bathroom, he
was collecting some of sandals around his
neighbourhood, he stopped the car and
motorcyle but he didnt ride on it and just
talked irrelevant sentences beli pasir....
The Patient began to stop work because he

had some weird behaviour.

Therefore, he was sent to his home by his

friend.

19th March 2015 (day of

admission)

The patient angry and rampage without any reason

he slamed the door and window, repeatedly, he destroyed
some households.
He was seen talk by himself when he was alone, had rigid
behaviour, opened his eyes widely, scratched the soil
repeatedly, talked by himself when he was alone
He feel suspicious to all of people
He hear bird sound when he was concious, although there is
no definite source of it.
He also hears someone whisp that said to him
sendal...baju...topi...kaos. He hears it in a concsious state
and there is nobody around him that whisp such like that.
He cant eat by himself
He didnt take a bath all day.

History of Past Illness

Psychiatric Illness
There is no history of psychiatric illness
General Medical Illness
There is no history of high fever, seizure, head
trauma, or any other serious illness which needs
hospitalization
Substance Abuse

History of smoking (one pack per day)

No history of use of drugs

Family History

There is no history of psychiatric illness

in his family

There is no history of high fever,

seizure, head trauma, or any other
serious illness which needs
hospitalization.

Progression of Illness
Symptom

2013

Role of Function

March
2015

GENOGRAM

EARLY CHILDHOOD PHASE (0-3 YEARS

OLD)
Psychomotoric (No Data)
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 Data)
There are patiens psychosocial such as:
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 Data)

Patient started saying bubling word (6-9 months).
Emotion (No Data)
Patient had reaction when playing, frightened by strangers,
when starting to show jealousy or competitiveness towards
other and toilet training.
Cognitive (No Data)
The patient can follow objects, recognizing her mother,
recognize her family members.
The patient first copied sounds that were heard, or
understanding simple orders.

INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor (No Data)
Patients first time riding a tricycle or bicycle, if patient ever
involved in any kind of sports.
Psychosocial (No Data)
Patient interaction with patients surrounding, no valid data
on when patient first entered primary school, on how well
patient handle seperation from parents, how well he play
with his new friend on first day school.
Communication (No Data)
Patient ability to make friends at school and how many
friends patient has during his school period.
Emotional (No Data)
Patients adaptation under stress, any incidents of
bedwetting were not known.
Cognitive
Patients study from primary school on 6th years old until
junior high school. Patient got bad grade at grade 4 th and

LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (No Data)
No data on when patient experience Wet Dream, hair
on armpits and pubis, etc
Psychomotor (No Data)
No data about patient hobbies.
Psychosocial (No Data)
Patient had told the parent about patient friend.
Emotional (No Data)
No valid data on patients reaction on playing, scared,
showed jealously or competitiveness
Communication (No Data)
The relationship between patient with parents and
other family is good

Eriksons Stages of Psychosocial

Development
Stage
Infancy (birth to 18
months)
Early childhood (2-3
years)
Preschool (3-5
years)
School age (6-11
years)
Adolescence (12-18
years)
Young adulthood
(19-40 years)

Basic Conflict
Trust vs mistrust

Important
Events
Feeding

Autonomy vs shame Toilet training

and doubt
Initiative vs guilt
Exploration
Industry vs
inferiority
Identity vs role
confusion
Intimacy vs
isolation

School
Social
relationships
Relationship

 Sosio-Economic History

Economic scale is low, the patient is a

construction workers.

Validity

Alloanamnesis : Valid Data

Autoanamnesis

: Valid Data

Physical Examination (March 19th

2015)

General Appearance: bad self grooming.

State of Consciousness
Neurological: (compos mentis)
Psychological: Impaired
Social: Impaired
Vital sign:
BP : 130/70 mmHg
HR:112 x/m
to : 36,5 C
RR : 24 x/m

General physical
examination

Head

normocephali, mouth deviation (-)

anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck

Thorax :

: normal, no rigidity, no palpable lymph nodes

Cor

: S1 S2 regular, murmur -, gallop

Lung

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

Abdomen :
flat, abdominal wall//chest wall, normal peristaltic, tympany

sound, tenderness -, 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
CN
CN
CN
CN
CN
CN
CN
CN
CN

I
:
II
:
III,IV,VI :
V
:
VII
:
VIII
:
IX
:
X
:
XI
:
XII
:

in
in
in
in
in
in
in
in
in
in

normal
normal
normal
normal
normal
normal
normal
normal
normal
normal

finding
finding
finding
finding
finding
finding
finding
finding
finding
finding

Neurological examination

Motoric

Upper extremities: tonus (+), trophy : eutrophic, power

of movement : shoulder joint : 5, elbow joint : 5, wrist

joint : 5, radial nerve function : 5, ulnar nerve function :
5, median nerve function : 5
Lower extremities: tonus (+), trophy : eutrophic, power
of movement : 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 abnormalities

Neurological
examination
Physiological

reflex

Upper extremities: biceps reflex (+), triceps reflex (+),

brachioradial (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological

reflex

Upper extremities: Hoffman (-), Tromner (-)

Lower extremities: babinski (-), chaddok (-),gordon

(-),oppenheim (-), 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

abnormalities), tip to toe walk (no abnormalities)

Mental State Examination

Appearance:
A male, look as his actual age, wear
complete clothes, bad self grooming.
Orientation:
Time : bad
People: bad
Place : bad
Situation: bad
Conciousness: Clear

Behavior
Normoactive
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare
Command automatism
Mutism

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

Inappropriat
e

Broad
Restrictive
Blunted
Flat
Labile

Disturbance in Perception

Hallucination

Auditory (+)
Taktil (-)
Visual (-)
Gustatory (-)
Olfaction (-)

Illusion

Auditory (-)
Taktil (-)
Visual (-)
Gustatory (-)
Olfaction (-)

Progression of Thought
Quality

Quantity

Normal
Logorrhea
Blocking
Remming
Mutism
Talkative

Coherent
Relevant
Irrelevant answer
Coprolalia
Incoherence
Flight of idea
Loosening of association
Neologisme
Circumtansiality
Tangentiality
Word salad
Echolalia

Content of Thought
Idea of Reference
Preoccupation
Obsession
Phobia
Fantasy
Delusion of Persecution
Delusion of Reference
Delusion of Envious
Delusion of Hypochondriac
Delusion of Magic-mystic
Idea of suicidal
Delusion of Grandiose

Form of Thought
Non

realistic

Cognitive Function

Level of education

: finished

Elementary School

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

Impulse Control When

Examined
Self control: Good
Patients response to examiners
questions: Enough

Insight
Impaired insight
Intellectual insight
True insight

RESUME

A man, 31 years old, married, unemployed, easily getting

angry, change in behavior, irritable, suspicious
Symptom:

Mental Status:

Impairment:

angry and rampage without any

reason, he slamed the door and
window, repeatedly, he
destroyed some households.
He talked by himself when he
was alone
had rigid behaviour,
opened his eyes widely,
scratched the soil repeatedly,
He feel suspicious to all of people
He hear bird sound when he was
concious, although there is no
definite source of it.
He also hears someone whisp
that said to him, hears it in a
concsious state and there is
nobody around him that whisp
such like that.

Behavior:
catalepsy
Atitude : Non
cooperative
Mood : Irritable
Affect :
Inappropriate,
blunted
Progression of
Thought:
remming,
coherence
Content of thought
: Thought of
broadcasting, idea
of suspicious
Form of thought :
non-realistic

Patient
decreased
socializatio
n
Patient
cant work
because his
concentrati
on is
decreased

Syndrome
Thought of broadcasting
Auditoric Hallucination
Affect blunted, Inappropriate
Non-Realistik Form Thought
Impaired Insight
Katatonik behaviour = catalepsy
Idea of suspicious
Auditoric Hallucination

catatonik behaviour = catalepsy

rigiditas

Syndrome
Schizophrenia

Syndrome
Schizofrenia
Paranoid
Syndrome
Schizofrenia
Katatonik

DIFFERENTIAL DIAGNOSIS
F20.0 Paranoid Schizophrenia
F20.2 Katatonik Schizophrenia

Multiaxial Diagnose
Axis
Axis
Axis
Axis
Axis

I :
II :
III:
IV
V:

F20.2 Katatonik schizophrenia

R46.8 Delayed diagnose
No diagnose
: Unclear
GAF 30-21

PLANNING
MANAGEMENT

Hospitalization
Pharmacotherapy
Psycho-education

PLANNING
MANAGEMENT
Hospitalization
The

purpose of hospitalization is to
decrease the symptoms, so patient can
handle patients self
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
IGD

O Haloperidol Inj 10mg IM

O Diazepam Inj 10 mg IM
Bangsal
O Risperidon
2 x 2 mg
O ECT

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 chemicals imbalance in the
brain, so we need various aspects for the
treatment.
Education
of the family to encourage
communication and understanding.
Help the patient when patient needs it.
Treat the patient according to the patients
ability, dont demand the patient more nor
less.

THANK YOU