MORNING REPORT

Monday, January 26th 2015

Supervisor:
dr. Sabar P Siregar Sp.KJ

PATIENTS IDENTITY
Name
: Mr N
Age
: 37 years old
Gender
: Male
Address
: Purworejo
Occupation
: Farmer
Marriage Status : Married
Religion
: Islam
Last Education : Elementary School

ALLOANAMNESIS
Guardian
Name : Mrs. R
Age
: 49 years old
Relation : Sister

CHIEF COMPLAINT
Patient
was
hospital by

brought

to

the

his sister
because he began to run naked along
the village.

STRESSOR
His wife had an affair with another man
since 1 year ago.

PROGRESSION OF ILLNESS
1 year before admision Early 2014

Patient started to talk himself after

having such a stressor, his wife
hand an affair with another man.
Patient
also
began
to
laugh
sometimes with no specific reason
and seems having conversation
with nobody.
But patient still worked normally
and make good relationship with
his friends.

1 year
2014

before

admision Early

His family brought him to RSU

Purworejo
to
get
medication.
Patient was not hospitalized.
He got some medicine but he didnt
take it regularly. And also didnt
came back to consult to the doctor
again.
Patient still worked normally and
sometimes stop his work due to the
symptom appeared.

2 day before admission

The
symptom
became
more
serious, he ran along the village
naked.
Throwing away households
Patient were holding dagger to
scare people.
He was scared that people near
him was trying to kill him.
Patient became more intense talk
and laugh.
Patient cannot communication with
his family
Patient told everyone in the village
that he is kalong ijo sakti and
nobody can beat him.

HISTORY OF PAST ILLNESS

Psychiatric illness
There was no history of psychiatric illness
General medical illness
There was no history of high fever, seizure, head
trauma, any other systemic disease.
Substance abuse
Drug abuse (-)
Tobacco use (+) Half Pack per day
Alcohol abuse (-)

HISTORY OF PERSONAL LIFE

1.

Prenatal and Perinatal History

2.

Early childhood phase

3.

Intermediate childhood

4.

Late childhood

5.

Adulthood

PRENATAL AND PERINATAL

The patient was the sixth child from

ten siblings.

No Valid Data on another information

about how the pregnancy, how mother
condition or who is the helper of labor.

2 DEVELOPMENTAL HISTORY (GROSS MOTORI

Ability

Result

Normal range

Elevating the head

Normal

0-3 months

Moving to supine
position on its own

Normal

3-6 months

Sitting

Normal

6-9 months

Standing

Normal

9-12 months

Walking

Normal

12-24 months

Climbing up the
ladder

Normal

24-36 bulan

Standing 1 foot /
jump

Normal

36-48 bulan

DEVELOPMENTAL HISTORY (FINEMOTORIC

Ability

Result

Normal range

Holding a pencil

Normal

3-6 months

Holding 2 objects at the same

time

Normal

6-9 months

Piling 2 cubes

Normal

9-12 months

Inserting objects into container

Normal

12-18 months

Rolling a ball

Normal

18-24 months

Doodling

Normal

24-36 months

Wearing shirt

Normal

36-48 months

DEVELOPMENTAL HISTORY (LANGUAGE)

Ability

Result

Normal range

Oooh-aah

Normal

0-3 months

Turning toward the sound

Normal

3-5 months

High-pitched sound

Normal

3-6 months

Voice without meaning (mamama,

Bababa)

Normal

6-9 months

Calling 2-3 syllables without

meaning

Normal

9-12 months

Calling 3-6 words that have meaning

Normal

18-24 months

Talking at least with two words

Normal

24-36 months

Mentioning name, age, and place

Normal

36-48 months

DEVELOPMENTAL HISTORY (SOCIAL &

PERSONAL)
Ability

Result

Normal range

Know their mother

Normal

0-3 months

Reach out

Normal

3-6 months

Clap

Normal

6-9 months

Playing peek a boo

Normal

6-9 months

Know their family

Normal

9-12 months

Appoint what he wants without

crying or whining

Normal

12-18 months

Tidy up toys

Normal

24-36 months

Playing with friends, follow the

rules of the game

Normal

36-48 months

3 INTERMEDIATE CHILDHOOD
(3-11 YEARS OLD )
Psychomotor

(NO VALID DATA)

No valid data on when patient first time
climbing the tree or play hide and seek games,
and 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 surrounding.
There were no data on when patient first
entered primary school, how well patient
handle separation from parents, how well he

Communication

(NO VALID DATA)

There were no valid data regarding patients
ability to make friends in school, and how
many friends patient have during her schooling
period.
Emotion

(NO VALID DATA)

No valid data on patient adaptation under
stress
Cognitive

(NO VALID DATA)

No valid data on patients grades in school

4 LATE CHILDHOOD AND TEENAGE PHASE

Sexual

Development Sign and Activity (NO

VALID DATA)
No data on when patient growth hair on armpits,
growth pubic hair and wet dream.
Psychomotor

(NO VALID DATA)

No data if patient had any favorite hobbies or games,
if patient involved in any kind of sports.
Psychosocial

( NO VALID DATA)
No valid data on relationship history of the
patients

Communication

(NO VALID DATA)

No valid data on how well the relationship
between patient with parents and other family.
Emotion

(NO VALID DATA)

No data if patient ever told friend or family
regarding any problems. No data if patient
attempted to break the rules (truant school
subject, fight with friends, bullying, ect) and
consuming alcohol, smoke and drugs

PRESCHOOL

Physical
-Physically active
-Rule of Three:

Cognitive
-Ego-centric, illogical,
magical thinking
3
-Explosion of
yrs,3 ft, 33 lbs.
vocabulary;
-Weight gain: 4-5 lbs
learning
syntax,grammar;
per year
understood by 75% of
-Growth: 3-4 inches
people by age 3
-Poor understanding of
per year
time, value, sequence
- Physically active,
of events
-Vivid imaginations;
cant sit still for long
some difficulty
-Clumsy throwing balls separating fantasy
-Refines complex
from reality
skills: hopping,

Social
Play:
Cooperative,imagina
tive, may involve
fantasy and imaginary
friends, takes turns in
games
Develops gross and
fine motor skills;
social skills;
experiment with social
roles;reduces fears
Wants to please adults

Physical
-Improving fine motor
skills and eye-hand
coordination: cut with
scissors, draw shapes
3 3,5 yr: most toilet
trained

Cognitive
-Accurate memory,
but more suggestible
than older children
-Primitive drawing,
cant
represent themselves
in drawing till age 4
-Dont realize others
have
different perspective
-Leave out important
facts
- May misinterpret
visual cues of
emotions
-Receptive language
better than expressive
till age 4

Social
-Development of
conscience:
-Incorporates parental
prohibitions; feels
guilty when
disobedient; simplistic
idea of
good and bad
behavior
-Curious about his and
others bodies, may
masturbate
-No sense of privacy
-Primitive, stereotypic
understanding of
gender roles

Emotional
Self-esteem based on what
others tell him or her
Increasing ability to control
emotions; less emotional
outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right
and wrong
Self-esteem reflects opinions of
significant others
Curious
Self-directed in many activities

Possible effects of maltreatment

Poor muscle tone, motor
coordination
Poor pronunciation, incomplete
sentences
Cognitive delays; inability to
concentrate
Cannot play cooperatively; lack
curiosity, absent imaginative and
fantasy play
Social immaturity: unable to share
or negotiate with peers; overly
bossy, aggressive, competitive
Attachment problems: overly
clingy, superficial attachments,
show little distress or over-react
when
separated from caregiver

Emotional

Possible effects of maltreatment

Underweight from malnourishment; small
stature
Excessively fearful, anxious, night terrors
Reminders of traumatic experience may trigger
severe anxiety, aggression, preoccupation
Lack impulse control, little ability to delay
gratification
Exaggerated response (tantrums, aggression) to
even mild stressors
Poor self esteem, confidence; absence of
initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses
Eneuresis, encopresis, self stimulating behavior
rocking, head-banging

SCHOOL AGED

Physical
Slow, steady
growth: 3 -4 inches
per year
Use physical
activities
to develop gross
and fine motor skills
Motor & perceptual
motor skills better
integrated
10-12 yr: puberty
begins for some
children

Cognitive
Use language as
acommunication
tool
Perspective taking:
5-8 yr: can
recognize others
perspectives, cant
assume the role of
the other
810 yr: recognize
difference between
behavior and intent;
age

Social
Friendships are
situation
specific
Understands
concepts
of right and wrong
Rules relied upon to
guide behavior and
play, and provide
child with structure
and security
5-6 yr: believe rules
can
be changed

Social
SCHOOL
AGED
7-8 yrs: strict adherence

Cognitive
Use language as
acommunication tool
10-11 yr: can accurately
recognize and consider
others viewpoints
Concrete operations:
Accurate perception of
events; rational, logical
thought; concrete thinking;
reflect upon self and attributes;
understands concepts of space,
time, dimension
Can remember events
from months, or years
earlier
More effective coping skills
Understands how his
behavior affects others

to rules
9-10 yrs: rules can be
negotiated
Begin understanding social
roles; regards them as inflexible;
can adapt behavior to fit
different situations; practices
social roles
Takes on more responsibilities at
home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self
interested exchanges

Emotional
Self esteem based on ability to perform and produce
Alternative strategies for dealing with frustrationand expressing
emotions
Sensitive to others opinions about themselves
6-9 yr: have questions about pregnancy, intercourse, sexual
wearing, look for nude pictures in books, magazines
10-12 yr: games with peeing, sexual activity (e.g., strip poker,
truth/dare, boy-girl relationships, flirting, some
kissing, stroking/rubbing, reenacting intercourse with clothes on)

Poor social/academic adjustment in school: preoccupied, easily frustrate

emotional outbursts, difficulty concentrating, can be overly reliant on
teachers; academic challenges are threatening, cause anxiety
Little impulse control, immediate gratification, inadequate coping skills,
anxiety, easily frustrated, may feel out of control
Extremes of emotions, emotional numbing; older children may selfmedicate to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting, lying, stealing,
breaking objects, verbal outbursts, swearing
Extreme reaction to perceived danger (i.e.,fight, flight, freeze respons
May be mistrustful of adults, or overly solicitous,manipulative
May speak in unrealistically glowing terms about his parents
Difficulties in peer relationships; feel inadequate around peers; overcontrolling
Unable to initiate, participate in, or complete activities, give up quickly
Attachment problems: may not be able to trust, tests commitment of fo
and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and younger

Physical

ADOLESCENTS

Growth spurt:
Girls: 11-14 yrs
Boys: 13-17 yrs
Puberty:
Girls: 11-14 yrs
Boys: 12-15 yrs
Youth acclimate to changes
in body

Cognitive

Formal operations: precursors in

early adolescence, more developed
in middle and
late adolescence, as follows:
Think hypothetically: calculate
consequences of thoughts and
actions without experiencing them;
consider a number of possibilities
and plan behavior accordingly
Think logically: identify and reject
hypotheses or possible outcomes
based on logic
Think hypothetically, abstractly,
logically
Think about thought: leads to
introspection and selfanalysis
Insight, perspective taking:
understand and consider others
perspectives, and perspectives of
social systems
Systematic problem solving: can
attack a problem, consider multiple

Social

Young (12 14):

Psychologically distance self
from parents;identify
with peer group; social status
largely related to group
membership; social acceptance
depends on conformity to
observable traits or roles; need
to be independent from all
adults; ambivalent about
sexual relationships, sexual
behavior is exploratory
Middle (15 17):
friendships based
on loyalty, understanding, trust;
self-revelationis first step
towards intimacy; conscious
choices about
adults to trust; respect honesty
& straight for wardness from
adults; may become sexually
active

Emotional
Psycho-social task is identity formation
Young adolescents (12-14): selfconscious
about physical appearance and early or late
development; body image rarely objective,
negatively affected by physical and sexual
abuse; emotionally labile; may over-react
to parental questions or criticisms; engage
in activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others values,
beliefs; forms identity by organizing
perceptions of ones attitudes, behaviors,
values into coherent whole; identity
includes positive self image comprised of
cognitive and affective components
Additional struggles with identity
formation include minority or biracial
status, being an adopted
child, gay/lesbian identity

Possible effects of maltreatment

All of the problems listed in school age
section
Identity confusion: inability to trust in self
to be a healthy adult; expect to fail; may
appear immobilized and without
Direction
Poor self esteem: pervasive feelings of
guilt, self-criticism, overly rigid
expectations for self, inadequacy
May overcompensate for negative
selfesteem by being narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and
aggressive, antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with
frequent and violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders

ADULTHOOD
Educational History
Elementary school. Was expelled from school
because of an economic problem.
Marriage Status
Married with one child. But his wife had an affair
with another man
Social Activity
Normal interaction with his family, friends, and
neighbors before sick.

 Occupational History
Patient ever wokred as a farmer for about 10
years
Current Situation
Currently live with his mother and seventh sister.
Religious History
Moslem; prayed rarely
Criminal History
No criminal history

Eriksons Stages of Psychosocial

Development
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

HISTORY
Psychosexual History

Patient psychosexual history is appropriate

to his gender. The patient realizes that he is
male and behaves according to his gender.

Family history
The patient is the sixth child from ten
siblings
The patient lived with his
mother and
seventh sister

GENOGRAM

Died
Patient
Man
Woman

Socio-Economic History
Economic scale : Low.

Validity
Alloanamnesis : Valid Data
Autoanamnesis : Valid Data

PROGRESSION OF ILLNESS
Symptom

2014

Role of Function

2015

MENTAL STATE

Appearance

A male, look equal to his age, wear

complete
clothes, poor self grooming.
State

of Consciousness
Cloudy

Speech

Quantity : Decrease
Quality : Loosening of Association

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Negativism
Cataplexy
Stereotipy
Mannerism
Automatism
Command
automatism
Bizarre

Mutism
Acathysia
Tic
Somnabulism
Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

Tremor
Floxilation
Anergy
Dischynesia
Muscle rigidity
Bradychynesia
Khorea
Convulsion
Dystonia
Aminia

Attitude
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Active

Infantile
Distrust
Labile
Rigid
Passive negativism
Stereotipy
Catalepsy
Cerea flexibility
Excited

Emotion
Mood

Hypothym
Euthymic
Elevated
Dysphoric
Euphoria
Expansive
Irritable
Agitation

Affect
Inappropriat
e
Restrictive
Blunted
Flat
Labile

Thought Progression
Quality

Quantity

Logorrhea
Blocking
Remming
Mutisme
Talkactive

Irrelevan answer
Incoherence
Flight of idea
Confabulation
Poverty of speech
Slow speech
Loosening of association
Neologisme
Circumstansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia

Disturbance of Perception
Hallucination
Auditory (+) The
patient told that
he is kalong ijo
sakti
Olfactory (-).
Visual (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Undeferrentiated (-)
Depersonalisation (-)

Illusion

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

Derealisation (-)

Content of thought
Idea

of Reference

Preoccupation

Delusion of Grandiose
Delusion of Control
Delusion of Influence

Obsession

Delusion of Passivity

Phobia
Delusion

of Persecution

Delusion of Perception

Delusion

of Reference

Thought of Echo

Delusion

of Envious

Thought Insertion

Delusion

of Hipochondry

Thought of withdrawal

Delusion
Fantasy

of Magic-Mystic

Thought Broadcasting
Cant be assesed

Form of Thought
Realistic
Non Realistic
Dereistic
Autism

Sensorium and Cognition

Level of education
: Low
General knowledge
: Good
Orientation of T/P/P/S :
Poor/Poor/Poor/Poor
Working/short/long memory: good
Writing and reading skills : Good
Ability to self care
: poor

Impulse Control When

Examined
Self control: bad
Patient response to examiners question:
Enough

Insight
Impaired insight (patient did not know
that she is mentally ill)
Intelectual Insight
True Insight

EXAMINATION

PHYSICAL EXAMINATION
Conciousness
Vital

: compos mentis

sign:

Blood pressure : 130/80 mmHg

Pulse rate
: 82 x/min
Temperature
: 36,5o C
RR
: 22 x/min

a. Head:
Normocephali, mouth deviation (-)
Anemic conjungtiva (-), icteric sclera (-), pupil
isocore
b. Neck: Normal, no rigidity, no palpable lymph
nodes
C. Thorax:
Cor : S1 S2 regular, murmur -, gallop Lung : Vesicular sound +/+, wheezing -/-,
ronchi -/d. Abdomen:
Flat, abdominal wall//chest wall, normal
peristaltic, tympany sound, tenderness -, mass
-, liver, spleen and kidney not papable

Cranial nerves examination:

CN
CN
CN
CN
CN
CN
CN
CN
CN
CN

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

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(-),

Motoric examination
Normal movement, good coordination, normal
strength

NEUROLOGICAL STATUS

Motorik

: Normotonus, good coordination of

movement
Meningeal

sign

Physiologic
Patologic

: negative

reflex : +/+

reflex

: -/-

RESUME

Mental Status

Symptoms
Wandered
around
Talk and laugh
alone
Holding knife to
scare people
He was scared
that people near
him was trying
to kill him
unable to sleep
Destroying
household
appliances

Disorientation
Behaviour : hyperactive
Attitude: tension
Mood : dysphoric
Affect: inappropriate,
blunted
Disturbance of
perception:
hallucination of auditory
(+) The patient heard
someone told that he is
kalong ijo sakti.
Thought progression:
Poverty of speech, Slow
speech, Circumtansiality
Quality: Decrease
Content of thought :
preoccupation,
delusional of grandiosa
Form of thought: Non
realistic

impairment

Did not
have any
passion for
working
Inability to
self care
Limited
social
interaction

Onset 1 years
ago

DIFFERENTIAL DIAGNOSIS
F20.0 Paranoid Schizophrenia
F25.0 Schizoaffective Disorder
Manic Type

MULTIAXIAL DIAGNOSIS
Axis I

: F20.0 Paranoid Schizophrenia

Axis II

: no diagnosis of axis II

Axis III

: no diagnosis of axis III

Axis IV

: His wife had an affair with other man

Axis V

: GAF Admission 20-11

PROBLEM RELATED TO THE PATIEN

Problem about patients life (social)
His

wife had an affair with other man

The patient became angry without any reason
Patient ever hold a blade to scare other vilager
Patient talk himself and also laugh himself.
Patient cannot communication with his family
Inability to self care

Problem about patients biological

state (biology)
There were abnormality imbalance
neurotransmitter,

3.Problem about patients mental state

(psychology)
Auditory hallucination: the patient
heard voice that told him he is kalong
ijo sakti

PLANNING MANAGEMENT

Emergency Department:
Inj. Haloperidol 1 amp (IM)
Inj. Diazepam 1 Amp (IV)
INPATIENT (HOSPITALIZATION)
Patient angry without any cause.
He hold knive to scare the vilager.
Maintenance
Haloperidol
=2 x 5mg/day
Suggest ECT

I Response
Target therapy : 50% decrease of symptoms
II REMISSION PHASE
Target therapy : 100% remission of symptom
Inpatient management
Improving the patient quality of life
Teach patient about his social & environment
(interact with his family, socialize with his neighbor
or friends, find a hobby to do on his spare time)
Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy

III RECOVERY PHASE

Continue

the medication, control to psychiatrist

Rehabilitation :
- Consult to psychologist to help patient finding
a hobby
- Help patient to interact normally with her
family and neighbor

THANK YOU