MORNING

REPORT

Saturday, May 17th 2014

SUPERVISOR
dr. Sabar P. Siregar, S

Patient Identity

Autoanamnesis
Name
: Mr. B
Sex
: Male
Age
: 24 years old
Address
: Purworedjo
Occupation
: Unemployed
Marital State
: Single
Alloanamnesis
Name
: Mrs. S
Sex
:Female
Age
: 54 years old
Relation
: Mother

Reason patient was brought to

emergency room
Patient was talking to himself, angry
without any reason, unable to sleep

Stressor

Unclear

Day of Admission
17th May 2014

Patient brought with the

complaints of:
talking to himself
angry without any
reason
unable to sleep

The patient didnt take any medicine

Brought to
hospital by his
mother

He didnt work
Poor utilization of leisure time
He couldnt socialize with friends

Past History
June 2013

Patient brought to RSJS by

his family because he was
mad without any reason. He
also disturbed his
neighbour. He was
hospitalized.
He didnt go to work
He cant utilize his leisure
time
He didnt socialize with
neighbor

Patient was given risperidone and clozapine and got bettter after care.
Patient discontinued medication after being discharged from hospital because he lives far from hospital (not acessible)

PSYCHIATRIC HISTORY

Hospitalized in RSJS for 20 days

in June 2013

Drugs consumption (-)

Alcohol consumption (-)
Cigarette Smoking (+)

Head injury (-)

Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)

Drugs and
alcohol abuse
history and
smoking
history

General
medical
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

FAMILY HISTORY
Patient

is the 3rd child of 5 siblings

Psychiatry

history in the family (-)

GENOGRAM

MALE

FEMALE

Patient

PSYCHOSEXUAL
HISTORY
Patient realizes that he is a male, and
interests to a female. His attitude is
appropriate as a male.

Progression of Disorder
Symptom

June
2013

Role Function

May
2014

Mental State
7th May 2014

BEHAVIOUR

Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre

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

ATTITUDE

Noncooperative
Indiferrent
Apathy
Tension
Dependent
Passive

Infantile
Distrust
Labile
Rigid
Passive
negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Emotion

Disturbance of Perception

Depersonalization (-)

Derealization (-)

Thought Progression

Content of Thought

Idea of Reference

Delusion of grandiose

Idea of Guilt

Delusion of Control

Preoccupation

Delusion of Influence

Obsession

Delusion of Passivity

Phobia

Delusion of Perception

Delusion of Persecution

Delusion of Suspicion

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion &

Delusion of Hypochondriac

Delusion of magic-mystic

withdrawal
Thought of Broadcasting

Form of Thought
Realistic

Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition

Level of education : finished junior high

school
General knowledge : cant be accessed
Orientation of time : bad
Orientations of place : bad
Orientations of people : bad
Orientations of situation : bad
Working/short/long memory: cant be accessed
Writing and reading skills : cant be accessed
Visuospatial : cant be accessed
Abstract thinking : cant be accessed
Ability to self care : cant be accessed

Impulse control
when examined

Insight

Physical State
Consciousnes
Vital

: compos mentis

sign :
Blood pressure
: 130/80 mmHg
Pulse rate
: 73 x/mnt
Temperature
: afebrile
Respiration rate
: 22 x/mnt

Review System

Head : normocephali, mouth deviation (-)

Eyes

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

Neck

: normal, no rigidity, no palpable lymph nodes

Thorax:
Cor

: S 1,2 regular

Lung

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

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2, motoric strength

Neurological exam : not examined

RESUME
Day of admission
Patient is a male, 53 years old, poor grooming, has a history of adminition in
psychiatric ward. Symptoms elevation started since half month ago.

Mental
Status

Symptoms
Got angry
easily
Cutting
neighbors
trees
Wandering
around
home
holding an
axe

Hypoactive

Attitude: Tension, labile

Mood: Euthymic

Affect: Restrictive

Perception: none

Thought Progression:
Blocking, poverty of
speech

- Form of Thought: Realistic

- Patients response to
question: bad
- Intelectual insight

Impairment
He didnt work
Poor utilization
of leisure time
He couldnt
socialize with
neighbor

Differential Diagnosis
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia

Multiaxial Diagnosis
Axis I

: F20.3 Undifferentiated
Schizophrenia
Z91.1 Noncompliance of
medication
Axis II : Z03.2 none
Axis III: none
Axis IV : Social problem (disturbing
neighbor)
Axis V
: GAF admission 20-11

PLANNING MANAGEMENT
Inpatient (hospitalization)
To reduce 50% the symptoms :
Got angry easily
Wandering around home holding
an axe
Cutting down neighbors trees
without any reason

RESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency department
Haloperidol inj 5 mg
Diazepam tab 5 mg
Maintenance
Haloperidol 2x5mg
Re-assess patient

REMISSION PHASE
Target therapy :
100% remission of symptom
Inpatient management
Continue the pharmacotherapy: maintenance
Haloperidol 2x5mg
Improving the patient quality of life :
Teach patient about his social & environment
(interact with his parents, socialize with his neighbor,
get a new job, find a hobby to spend his spare time)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy

RECOVERY PHASE
- Continue medication, control to
psychiatric
- Rehabilitation : help patient to find a
hobby, help patient to interact
normally with his family and neighbor
- Family education

Target therapy : 100% remission of

symptom within 1 year.

Thank You