MORNING REPORT

Wednesday evening, 12th February 2014

SUPERVISOR
dr. Sabar P. Siregar, Sp.KJ
Identity
Name : Bpk S
Sex : Male
Age : 61 years old
Address : Temanggung
Occupation : Laborer
Patient was brought to the emergency unit
by his wife.
The reason of patient was brought to
hospital

Patient looked confuse

and irritable.
 STRESSOR

Her husband passed

away
Present History
4 days ago

• patient was admitted to  did not work since 6

RS Temanggung due to months ago.
slurred speech and  Poor utilization of leisure
hypertension.
time
• In RS, patient always felt
 Social withdrawal
irritable, and kept on
 He can not take care of
removing the iv line.
• Patient seems blank, and himself
day dreaming.
 Present History
Day of admission

• Patient showed blank expression and

irritable.
•Patient tried to untie himself.

did not work since 6 months ago.

Poor utilization of leisure time
Social withdrawal
Didn’t want to take a bath
Psychiatric History
• 3 moths ago, patient was brought to outpatient
clinic with symptoms of auditory hallucination,
visual hallucination, kept wandering, feeling sad,
and talking to himself.
• Then patient was diagnosed with undifferentiated
schizophrenia (F20.3)
• Patient did not control to doctor after 1 month
 •Head injury (-)
•Hypertension (-)
General •Convulsion (-)
medical •Asthma (-)
history •Allergy (-)
•History of admission (-)

Drugs and
alcohol • Drugs consumption (-)
abuse • Alcohol consumption (-)
history and • Cigarette Smoking (-)
smoking
history
 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 saying words 1 year like ‘mom’ or ‘dad’.
(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 patient interaction with his surrounding, no valid data on
when patient first entered primary school, on how well patient handle
separation from parent, how well he play with his new friend on first day
school.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at school and how
many friends patient have during his 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 VALID DATA)
 No data on when patient first experience of wet dream 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)
 Patient had never been told the parent about patient’s friend.
Emotional (NO VALID DATA)
 No valid data on patient’s reaction on playing, scared, showed jealously or
competitiveness
Communication (NO VALID DATA)
 No valid data on how well the relationship between patient with parent
and other family.
ADULTHOOD
 Educational History
Elementary School
Patient decided to discontinue study.  Current Situation
He lives with his wife and youngest
 Occupational history daughter.
Labour

 Marital Status
married

 Criminal History
No

 Social Activity
Good Relationship
 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 Toilet training
(2-3 years) doubt
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

 Patient is the first child out of two

siblings.

 Psychiatry history in the family (-)

Genogram • Suffers from
mental illness
• Female
• Male
 Psychosexual
history
 Cannot be evaluated because the patient has been
sedated.
Socio-economic history

• Economic scale : average

Validity

• Alloanamnesis : valid
• Autoanamnesis : valid
Progression of disorder

Symptom

Des 13 Feb 3

Role
function
 Mental State
(Wednesday, 12th February 2014)

Appearance
• A woman, appropriate to his age, completely
clothed
State of Consciousness
• Clear

Speech
• Quantity : decreased
• Quality : decreased
 Behaviour Difficult to
assess

• 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
Difficult to
assess

• Cooperative • Infantile
• Non-cooperative • Distrust
• Labile
• Indiferrent
• Rigid
• Apathy
• Passive negativism
• Tension • Stereotypy
• Dependent • Catalepsy
• Passive • Cerea flexibility
• Excitement
 Emotion Difficult to
assess

Mood Affect
• Dysphoric • Appropriate
• Euthymic • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
• Agitation
• Can’t be assesed
Disturbance of perception
Difficult to
assess

Hallucination Illusion

• Auditory (+) • Auditory (-)

• Visual (+) • Visual (-)
• Olfactory (-) • Olfactory (-)
• Gustatory (-) • Gustatory (-)
• Tactile (-) • Tactile (-)
• Somatic (-) • Somatic (-)

Depersonalization (-) Derealization (-)

 Difficult to
Thought progression assess

Quantity Quality
• Irrelevant answer
• Incoherence
• Logorrhea • Flight of idea
• Blocking • Poverty of speech
• Confabulation
• Remming • Loosening of association
• Mutism • Neologisme
• • Circumtansiality
Talk active • Tangential
• Verbigrasi
• Perseverasi
• Sound association
• Word salad
• Echolalia
Content of thought Difficult to
assess

• 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 Suspicious

• Delusion of Reference • Thought of Echo

• Delusion of Envious • Thought of

• Delusion of Hipochondry Insertion/withdrawal

• Delusion of magic-mystic • Thought of Broadcasting

Form of thought Difficult to
assess

• Realistic
• Non Realistic
• Dereistic
• Autistic
• Cannot be evaluated
 Difficult to
Sensorium and Cognition assess

 Level of education : Low

 General knowledge :-
 Orientation of time :-
 Orientations of place :-
 Orientations of peoples : -
 Orientations of situation :-
 Working/short/long memory: -
 Writing and reading skills :-
 Visuospatial :-
 Abstract thinking :-
 Ability to self care :-
 Difficult to
assess

Impulse control Insight

when examined • Impaired
• Self control: Poor insight
• Patient response to • Intellectual
examiners Insight
question: Enough • True Insight
Internal Status
 Consciousnes : unclear
 Vital sign :
◦ Blood pressure : 140/75 mmHg
◦ Pulse rate : 81x/mnt
◦ Temperature : Afebris
◦ RR : 16 x/mnt
 Head : normocephali, mouth devation (-)

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

 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”, motoric strength

5 5
 Neurological exam : not examined 5 5
 RESUME
Onset : day of admission

Symptom Mental Impairment

s Status
• Difficult to evaluate

• He does not
Got angry and work anymore
wandering • Poor hygiene
• Poor
around sparetime
management
 Differential Diagnosis

F05.0 Delirium not superimposed

on dementia
F06.1 Organic catatonic disorder
F20.3 Undifferentiated
schizophrenia
 Multiaxial Diagnosis
Axis I : F05.0 Delirium not superimposed on
dementia
Axis II: R46.8 delayed diagnosis of axis II
Axis III : Hypertension grade I and CVA
Axis IV : Unclear
Axis V : GAF admission 20-11
PLANNING MANAGEMENT
Inpatient (hospitalization)
The patient looked irritable that was
disrupting and endanger himself.

Remissio
Response Recovery
n
RESPONSE PHASE
Emergency department
Antipsychotics : Inj. Haloperidol 5mg
i.m.
Inf. Assering 20 drop per minute
fixation
Ward (routine therapy)
Antipsychotics : Tab Haloperidol 5mg s2dd
Antihypertension : Tab Captopril 25 mg s2dd

Re-assess patient when cooperative

Blood routine test and chemistry blood test
Consult neurologist
REMISSION PHASE
Inpatient management
Pharmacotherapy
Psychosocial rehabilitation
Education to family

Outpatient management
Pharmacotherapy
RECOVERY PHASE
Outpatient management
Pharmacotherapy
Psychotherapy
Thank You…