MORNING REPORT

Presented by Mita Novita Co-assistant

Gadjah Mada University on 28th
September 2014

Patients Identity
1.
2.
3.
4.
5.
6.
7.
8.

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mr. S
: 37 years old
: Male
: Kebumen
: Unemployed
: Single (unmarried)
: Javanese
: Elementary School

Identity
Alloanamnesis was conducted to :
I
Name

Mr. M

Age

42 years old

Sex

Male

Address

Kebumen

Job

Mechant

Educational
status

Elementary
School

Relationship

Brother

Duration of
relationship

20 years

Strength of
relationship

Medium

PSYCHIATRIC HISTORY
Morning Report
Sunday September 28th, 2014

Chief Complaint
Afraid someone want to kill him
Confused
Destroyed
Wandering around

History of Present Illness

3 years ago (2011)

2 years ago
(2012)

Patient was dismissal by his boss from

office because no reason.

Patient hear and felt someone

wanted to kill him. He felt chased by
someone. Patients also felt confused
and often strayed away. His family then
took him to RSJ Magelang. Afterwards
patient was hospitalized

1 year ago
(2013)

2 months ago
(2014)

Day of admission

Patient again feared will be killed

because he didnt take medications.
Patient preferred to be alone, ran
around the house, and did nothing.
Patient was then taken again to RSJ
Magelang.
Symptoms felt by patient repeated,
because he didnt take medications.
Patient was taken to RS Solo and
hospitalized for 1 month. Patient then
was allowed back home.

Patient isolated himself, didnt want to

interact with his surroundings, and
feared will be killed. Patient heard
voices saying will kill him and saw
figures of thugs who always chased
him.

Stressor
Patient is dismissal
Feeling lonely
Unemployed.

History of Past Illness

Psychiatric illness
There is no history of psychiatric illness in this patie

nt
General medical illness
There is no history of high fever, seizure, head trau
ma, or any other serious illness which needs hospita
lization
Substance abuse
No History of alcohol and narcotic abuse
No History of sleep drug usage
No History of smokes cigarette

Depiction of Illness
Symptoms
2012

Role
Function

2013

2014

Now

Family History
There is no history of psychiatric illness in p

atients family

Genogram

History of Personal Life

Prenatal and perinatal
No valid data on patients mother age when he

was pregnant.
No valid data whether patients mother was heal
thy or not when he was pregnant
No valid data about patients birth place (house
or hospital) and who was assisted the labour.
No valid data of patients immunization status

History of Personal Life

Early childhood phase (0-3 years old)

Psychomotoric
- There were no valid data on patients growth and development
- 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
- There were no valid data on patients growth and development
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 pla
ying claps with others (6-9 months)

History of Personal Life

Communication
- There were no valid data on when patient started bubbling (6-9 month
s)
Emotion
- There were no valid data on patients reaction when playing, frightene
d by strangers, when starting to show jealousy or competitiveness towa
rds other and toilet training
Cognitive
There were no valid data such as:
- which age the patient can follow objects, recognizing his mother, rec
ognize his family members.
- when the patient first copied sounds that were heard, or understandi
ng simple orders.

History of Personal Life

Intermediate childhood phase (3-11 years old)

Psychomotor
No valid data on when patients first time playing hide and seek and other moto
r skills
Psychosocial
No valid data about the patient's earliest friendships, personal relationships, and
the patient's social popularity and participation in group or gang activities.
Communication
No valid data about the number and the closeness of the patient's friends, whet
her the patient took the role of a leader or a follower, and the patient's social p
opularity and participation in group activities.
Emotional
No valid data about patient's early school experiences, especially how the patie
nt first tolerated being separated from his or her mother, cooperate with peers,
to be fair, to understand and comply with rules, and to develop an early conscie
nce
Cognitive
No valid data on history of the patient's learning disability, learning to read and
developing other intellectual skills

History of Personal Life

Late childhood and teenage phase (11-18 years old)

Sexual development signs & activity

No valid data on when patient get wet dream. he is attracted to opposite sex.
Psychomotor and Cognitive
No valid data on patient's participation in sports and hobbies, learning to read an
d other intellectual and motor skills, learning disabilities and their management a
nd effects on the child
Psychosocial
No valid data on attitudes toward sibling(s) and playmates, number and closeness

of friends, leader or follower, social popularity, participation in group or gang acti

vities, idealized figures, patterns of aggression, passivity, anxiety, antisocial behavi
or

Emotional
No valid data about any emotional or physical problems that may have first appea

red during this phase. (Nightmares, phobias, bed-wetting, running away, delinqu
ency, smoking, alcohol or other substance use, anorexia, bulimia, weight problem
s, feelings of inferiority, depression, suicidal ideas and acts)
Communication
No valid data about patients the number and the closeness of the patient's friend

s, whether the patient took the role of a leader or a follower, and the patient's so
cial popularity and participation in group or gang activities.

History of Personal Life

Adulthood phase (18 years old-now)

Educational History
He graduated Elementary School.

Occupational history
Patient worked in construction for 1 years. Dismissal of the patient by his
boss no reason.

Marital Status
Single (unmarried)

Criminal History
No criminal history

Social Activity
Before sick, the patient oftenly participated in social activities in his
village and make friends with his friends

Current Situation
He lives with parents

Eriksons stages of psychosocial developm

ent
Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

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

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)

Maturity
(65- death)

History of Personal Life

Psychosexual history and sexual development
Patient realizes that he is a male, and interested in f

emale. His attitude is appropriate as a male.

Patient was taught to be a male and played with his
male peers.
There is no valid data about his first wet dream
Socioeconomic history
Patient doesnt have any job now
Economic scale : low
Degree of validity : doubtful

EXAMINATION

Physical Examination
Consciousnes
Vital

: compos mentis

sign :
Blood pressure
: 120/80 mmHg
Pulse rate
: 80 x/mnt
Temperature
: Afebris
RR
: 20 x/mnt

Review System
Head

normocephali, mouth deviation (-)

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

Neck

: normal, no rigidity, no palpable lymph nodes

Thorax

Cor : S1 S2 regular, murmur -, gallop -

Lung
Abdomen

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

flat, abdominal wall//chest wall, normal peristaltic, tympany soun

d, tenderness -, mass -, liver, spleen and kidney not papable

Extremity : Warm acral, capp refill <2, edema (-)

Neurogical Examination
Cranial nerves examination:
CN I
: in normal finding
CN II
: in normal finding
CN III,IV,VI
: in normal finding
CN V
: in normal finding
CN VII
: in normal finding
CN VIII
: in normal finding
CN IX
: in normal finding
CN X
: in normal finding
CN XI
: in normal finding
CN XII
: in normal finding

Neurogical 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 (-)

Motoric examination
Normal movement, good coordination, normal strength, euthrophy,
normal ROM

Mental State Examination

Appearance:
a man, appropriate to his age, completel

y clothed, less self care

State of consciousness: clear
Speech:
Responds only when asked, intonation a

nd speech volume low, clear articulation,

speech productivity low

Mental State Examination

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

Acathysia

Mental State Examination

Attitude:
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile

Labile
Rigid
Passive negativism
Stereotypy
Catalepsy
Cerea flexibility
Excited

Mental State Examination

Emotion:

Mental State Examination

Disturbance of Perception

Depersonalization (-)

Derealization (-)

Mental State Examination

Thought Progression

Mental State Examination

Content
of Thought
Idea of Reference

Idea of grandiose

Delusion of Grandiose

Preoccupation

Delusion of Control

Obsession

Delusion of Religion

Phobia

Delusion of Influence

Fantasy

Delusion of Passivity

Delusion of Persecution

Delusion of Perception

Delusion of Reference

Delusion of Suspicion

Delusion of Envious

Thought of Echo

Delusion of Hypochondriac

Thought of Insertion & withdrawal

Delusion of Magic-mystic

Thought of Broadcasting

Mental State Examination

Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated

Sensorium and Cognition

Level of education : finished senior high school

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

Impulse control when examined

Self control: good
Patient response to examiners question: good

Insight
Impaired insight
Intellectual Insight
True Insight

RESUME

RESUME
Day of admission
Mental
Impairment
Status
-Behavior: hypoactive
-Attitude: cooperative
-Affect: appropriate, flat
-Mood : dysphoric

Afraid
someone want
to kill him,
confused,
destroyed
wandering
around

-Thought progression:
- Quantity : decreased
- Quality : decreased
-Form of thought : non realistic
-Content of thought : idea of
reference, delusion of suspicious,
delusion of control, thought of
insertion and withdrawal,
delusion of persecution
-Disturbance of perception :
halucination auditory, visual
-Patients response to question :
enough
- Impaired insight

He couldnt
take care of
himself

Symptom Grouping (Syndrome)

Symptoms

Syndrome

Flatten affect
Thought of insertion and
withdrawal
Delusion of control
Delusion of suspicious

Psychotic syndrome

Delusion of persecution
Auditory hallucination
Visual hallucination
Idea of reference
hypoactive
remming
Anhedonia
Anenergia

Depression syndrome

DIAGNOSIS

Differential Diagnosis
F20.0 Schizophrenia Paranoid
F20.2 Schizophrenia Catatonic
F25.1 Schizoaffective Depressive Type

Multiaxial Diagnosis
Axis I : F20.0 Schizophrenia Paranoid
Axis II : R 46.8 no diagnosis yet
Axis III

: no axis III diagnosis yet

Axis IV
: unemployed
Axis V : GAF admission 20-11

MANAGEMENT

Patients problems
Biological problem
Positive symptoms because of amount of dopamine in the post sin
aps neuron
Psychological problems
He cannot resolve the problem well

Social problem
unemployed

Management Planning
Hospitalization

Feared with no reason

Confused
Wandering around
Poor self care

Response Phase
Target therapy :
50% decrease of symptoms

Emergency department
Diazepam inj 5 mg iv (sedative and muscle relaxant)
Haloperidol 5mg im (reduced positive symptoms)

Maintenance
Haloperidol 5 mg po 2dd1

Re-assess patient

Remission Phase
Target therapy :
100% remission of symptom

Inpatient management
Risperidone 2mg 1ddI
Improving the patient quality of life :
Teach patient about his social & environment (interact with his family, so
cialize with his neighbor or friends, find a hobby to do on his spare time)

Outpatient management
Pharmacotherapy
Psychosocial therapy

Recovery Phase
Continue the medication
Rehabilitation :
- Help patient to interact normally with his fami

ly and neighbor
- Family education
- Help patient to find a hobby,

THANK YOU