MORNING

REPORT
April 10th 2014

Supervisor :
dr. Sabar P. Siregar, Sp. Kj
Patient Identity
 Name : Mr. S
 Age : 24 years old
 Sex : Male
 Ethnic : Javanese
 Address : Temanggung
 Occupation : Unemployed
 Marital Status : Single
 Education : Junior High School
Alloanamnesis

 Name : Mr. A
 Sex : Male
 Age : 43 years old
 Relation : Caretaker of rehabilition
 Reason patient brought to emergency
room

Patient don’t want to talked and ran away

from rehabilitation
Stressor

Unknown ( Because there is not valid data)

 Present Psychiatric History
Patient has been brought by caretaker of
rehabilitation to IGD RSJ Soerojo because of don’t want to
talk since he came to rehabilitation.Two days ago patient
has run away from rehabilitation and today they found
patient in temanggung.
Symptoms:
Silent
Apathetic
Social withdrawal
Loss of hygiene
Loss of appetite
Impairment:
 He didn’t work
 Sleep disorder
 Not eat or drinks
 Unwashed
 • Head injury (-)
General medical • Hypertension (-)
history • Convulsion (-)
• Asthma (-)
• Allergy (-)
• History of admission (-)

 Drugs, alcohol •Drugs consumption (-)

abuse, and • Alcohol consumption (-)
smoking history
• Cigarette Smoking (-)
 EARLY CHILDHOOD PHASE
(0-3 YEARS OLD)
Psychomotoric (NO VALID DATA)
• There were no valid data on 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 VALID DATA)
• There were no valid data on which age patient
• 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 VALID DATA)

• There were no valid data on when patient
started bubbling (6-9 months)
Emotion (NO VALID DATA)
 There were no valid data of patient’s reaction
when playing, frightened by strangers, when
starting to show jealousy or competitiveness
towards other and toilet training.

Cognitive (NO VALID DATA)

 There were no valid data on which age the
patient can follow objects, recognizing her
mother, recognize her family members.
 There were no valid data on when the patient
first copied sounds that were heard, or
understanding simple orders.
 INTERMEDIATE CHILDHOOD
(3-11 YEARS OLD)
Psychomotor (NO VALID DATA)
No valid data on when patient’s first
time playing hide and seek or if patient
ever involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data on how patient
socialized with her surrounding
Communication (NO VALID DATA)
 No valid data regarding patient ability to make
friends at school and how many friends patient
have during her school period
Emotional (NO VALID DATA)
 No valid data on patient’s adaptation under stress,
any incidents of bedwetting were not known.
Cognitive (NO VALID DATA)
 No valid data on patient’s cognitive.
LATE CHILDHOOD & TEENAGE
PHASE
Sexual development signs & activity
 No vaid data when patient first
experience of menstruation etc.

Psychomotor (NO VALID DATA)

 No data if patient had any favourite
hobbies or games, if patient involved
in any kind of sports.
Psychosocial
No valid data

Emotional (NO VALID DATA)

 No valid data on patient’s reaction on
playing, scared, showed jealously or
competitiveness

Communication
No valid data
ADULTHOOD
 Educational History
No valid data

 Occupational history
He didn’t worked

 Marital Status
Single
 Criminal History
None

 Social Activity
No valid data

 Current Situation
No valid data
 Erikson’s stages of psychosocial development
Stage Basic Conflict Important Events
Infancy Trust vs mistrust Feeding
(birth to 18 months)
Early childhood Autonomy vs shame and doubt Toilet training
(2-3 years)
Preschool Initiative vs guilt Exploration
(3-5 years)
School age Industry vs inferiority School
(6-11 years)
Adolescence Identity vs role confusion Social relationships
(12-18 years)
Young Adulthood Intimacy vs isolation Relationship
(19-40 years)
Middle adulthood Generativity vs stagnation Work and parenthood
(40-65 years)
Maturity Ego integrity vs despair Reflection on life
(65- death)
Family History

 Psychiatry history in family

( No valid data)
GENOGRAM (no valid data)

Male Female Patient Lives together

Progression of Disorder
Symptom

Can not be described

2008 2014 2015

Can not be described

Role function
Mental State
(Thursday 09th April 2015)
Behaviour
•Hypoactive •Command automatism
•Hyperactive •Mutism
•Echopraxia •Acathysia
•Catatonia •Tic
•Active negativism •Somnabulism
•Cataplexy •Psychomotor agitation
•Streotypy •Compulsive
•Mannerism •Ataxia
•Automatism •Mimicry
•Bizarre •Aggresive
•Impulsive
•Abulia
Attitude
• Non-cooperative •Infantile
• Indiferrent •Distrust
•Labile
• Apathy
•Rigid
• Tension
•Passive negativism
• Dependent •Stereotypy
• Passive •Catalepsy
•Cerea flexibility
•Excited
Disturbance of Perception
Thought Progression
Content of Thought
• Idea of Reference
• Idea of Guilt
• Preoccupation
• Obsession
• Phobia
• Delusion of Persecution
• Delusion of Reference
• Delusion of Envious
• Delusion of Hipochondry
• Delusion of magic-mystic
• Delusion of grandiose
• Delusion of Control
• Delusion of Influence
• Delusion of Passivity
• Delusion of Perception
• Delusion of Suspicious
• Thought of Echo
• Thought of Insertion /
withdrawal
• Thought of Broadcasting
• Idea of suicide
Form of Thought
• Realistic
• Non Realistic
• Dereistic
• Autism
 Sensorium and Cognition
 Level of education : bad
 General knowledge :-
 Orientation of time :-
 Orientations of place :-
 Orientations of peoples : -
 Orientations of situation : -
 Working/short/long memory :-
 Writing and reading skills: -
 Visuospatial : can’t be assessed
 Abstract thinking : can’t be assessed
 Ability to self care : bad
 Physical Status
Consciousnes : compos mentis
Vital sign :
◦ Blood pressure : 160/100 mmHg
◦ Pulse rate : 103 x/mnt
◦ Temperature : Afebris
◦ RR : 20 x/mnt
 Head : normocephali

 Eyes : anemic conjungtiva -/-, icteric sclera -/-, pupil

isocore , secret (+) , konjungtiva injection (+)

 Neck : normal, no rigidity, no palpable lymph nodes

 Thorax:

Cor : S 1,2 Sound and normal

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

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

 Extremity : Warm acral, capp refill <2”, tremor (-)

 Neurological exam : not examined

Resume
Mental Status Impairment
-Behavior: hipoactive
-Attitude: not cooperative
Mood: can’t be assesed
Affect: blunted
 Differential Diagnosis
F20.2 Skizofrenia Katatonik
F20.3 Skizofrenia Tak Terinci
 skizoafektif tipe campuran
Multiaxial Diagnosis

Axis I : F 20.5 Skizofrenia Residual

Axis II : Z03.2 No diagnose
Axis III : hypertension
Axis IV : Unclear (no valid data)
Axis V : GAF on admission 20-11
 Problem related to the patient
1. Psychology Problem
-
2. Social Problem
-
3. Problem about patient’s biological state
-
Planning Management
Inpatient (hospitalization)
Purpose of hospitalization is to decrease the
symptoms :
 Silent
 Apathetic
 Social withdrawal
 Loss of hygiene
 Loss of appetite
Response Phase
Target therapy : 50% decrease of symptoms

Emergency department

Antipsychotics :
Risperidone 2 x 2 mg / day
Remission Phase
Target therapy :
100% remission of symptoms
Inpatient management
1. Continue the pharmacotherapy:
Risperidone 2 x 2 mg Oral
2. Improving the patient quality of life :
Teach patient about his social &
environment
(clean the floor, washing the dishes, etc)
Outpatient management
1. Pharmacotherapy
2. Psychosocial therapy
Recovery Phase

Target therapy : 100% remission of symptom

within 1 year.
THANK
YOU