MORNING REPORT

Sunday, September 28th

2014
Nuardi Yusuf
Mita Novita
Dakshnamoorthy Vythinathan

SUPERVISOR
dr. Sabar P. Siregar, S

Name
Sex
Age
Address
Occupation
Marital State

:
:
:
:
:
:

Mrs. T
Female
30 years old
Magelang
Unemployed
Married

RELATIVEs IDENTITY
Name
: Mr. S
Sex
: Male
Age
: 35 years old
Relation : Cousin (Known patient
since
childhood
approximately 30
years)

Patient has been :

Patient gets angry easily
Patient often becomes raged
Patient attempted to strangle her own mother

The rejection and constant ill treatment by

parents and in laws

CURRENT PSYCHIATRIC HISTORY

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 patients 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.

Psychomotor (NO VALID DATA)

No valid data on when patients first time playing hide and
seek, hop scotch, climbing trees, five stones or if patient ever
involved in any kind of sports.
Psychosocial (NO VALID DATA)
Patient was an extrovert child and her ability to communicate
with other people is good.
Communication
Patients ability to make friends at school is good and have lots
friends during childhood.
Emotional (NO VALID DATA)
No valid data on patients emotional history. Event of tantrum,
panicking or elation is not available.
Cognitive
Patient was and average student in elementary and junior high
school. Reason to not continue studies is not known.

Sexual development signs & activity (NO VALID DATA)

No data on when patient first experience of menarche, etc.
Psychomotor (NO VALID DATA)
No valid data on patients favourite hobbies or games, if
patient involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data regarding patient psychosocial.
Emotional (NO VALID DATA)
No valid data on patients emotional.
Communication (NO VALID DATA)
No valid data regarding patient ability to make friends at
school and how many friends patient have during her high
school period

Educational History
No specific
achievements
Occupational history
She has never been
employed
Marital Status
Patients history in
dating and
relationship is
unavailable. Patient
got married about 6
years ago with a
man of her choice.
They have one son
aged 5 years old.

Criminal History
No criminal
history
Social Activity
Before she was
sick, she had
many friends and
no difficulty to
make new friends
Current Situation
She lives with her
parents and her
older brother
often comes to

(NO VALID DATA)

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

 Patient

No

is the 4th child from 4 siblings

psychiatric history in the family

GENOGRAM

MALE

FEMALE

Mental disorder

R.I.P

Patien
t

 Patient realizes that she is

female
Is interested in males
Her attitude is appropriate as
a female

Progression of Disorder
Symptom

5 years ago

Role Function

MENTAL STATE

28th September 20

BEHAVIOUR
Normoactive
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active
negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizarre

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

ATTITUDE

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

Idea of Guilt

Preoccupation

Delusion of grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Obsession

Phobia

Delusion of Perception

Delusion of Persecution

Delusion of Suspicious

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of insertion

Delusion of Hipochondry

Thought of Withdrawal

Delusion of magic-mystic

Thought of Broadcasting

FORM OF THOUGHT
Non Realistic

Dereistic
Autism
Cannot be evaluated

SENSORIUM AND COGNITION

Level of education
:
General knowledge
:
Orientation of time
:
Orientations of place
:
Orientations of people
:
Orientations of situation
:
Working/short/long memory
Writing and reading skills :
Visuospatial
:
Abstract thinking
:
Ability to self care
:

junior high school

good
good
good
good
good
: good
good
not assessed
not assessed
good

PHYSICAL STATE
Consciousnes : compos mentis
Vital sign
Blood pressure
mmHg
Pulse rate
Temperature
RR
x/mnt

: 120/90
: 80 x/mnt
: Afebrile
: 20

Head

: normocephali, mouth deviation (-)

Eyes

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

pupil isocore

Neck

Thorax

: normal, no rigidity, no palpable lymph nodes

Cor

: S 1,2 regular

Lung

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

Abdomen

: Pain (-) , normal peristaltic, tympany

sound

Extremity

: Warm acral, capp refill <2

Neurological exam : not examined

A woman, 30 years old, appropriate for

her age
Reasons to be brought to hospital are:
Patient got angry and tried to harm her
own mother. Patient also talks by
herself, laughs inappropriately, disturbs
the neighbours, destroys things in the
neighbourhood. Patient becomes easily
angered and goes on a rampage

DAY OF ADMISSION

Mental Status
- Mood: euthymic

Talks and
laughs by
herself
Patient
gets angry
easily
Patient
goes into a
rampage

Affect: blunted

Behaviour: normoactive

Attitude: indifferent

Perception: Hallucination
visual (+), hallucination
auditoric (+)

Impairment
-

Thought Progression: talk

active, incoherence, flight of idea
-

Form of Thought: Non

realistic

Content of thought: Idea of

reference
-Patients

response to
question: good
-

Impaired insight

Able to do
house
chores but
often
inapparopria
te.
Self care is
still present
but patient
showers
more
frequently.
Unable to
socialise
with other
ppl

DIFFERENTIAL DIAGNOSIS
F20.0 paranoid schizophrenia
F20.5 residual schizophrenia
F25.0 schizoaffective disorder mania type

MULTIAXIAL DIAGNOSIS
Axis I
: F 20.0 schizophrenia
paranoid
Axis II
: Z 03.2 No diagnosis
Axis III
: No diagnosis
Axis IV
: Problem with her
parents and in- laws (Her
marriage is not blessed)
Axis V
: GAF admission 20-11

1.

Problem about patients life

Patient has been in a constant emotional stress by her
parents and in laws ever since her marriage. Since birth her
parents had given her to the grandparents to be taken care.
After junior high she went back to stay with her parents.
2. Problem about patients biological state
Her brain is in an over active state. There is an increase in
the activity of neurotransmitters namely dopamine
-

Inpatient (hospitalization):
Talked and laughed by herself
Patient gets angry easily
Patient goes into a rampage
Harms people around her

TARGET THERAPY : 50% decrease of

symptoms
EMERGENCY DEPARTMENT
Haloperidol
5 mg i.m
-(To reduce positive symptoms)
Diazepam 5 mg i.v
-(Sedative & Muscle Relaxant)

MAINTENANCE
Haloperidol 5mg P.O. for reducing positive
symptoms
RE-ASSESS PATIENT

TARGET THERAPY : 100% decrease of

symptoms

MAINTENANCE
Risperidone 2 mg P.O.
Atypical antipsychotic for long term
medication and minimalise side effects
and addiction.
Psychotherapy CBT
RE-ASSESS PATIENT

TARGET THERAPY :Patient is able to

manage problems and deal with external
stressor
MAINTENANCE
Continue medication and follow up with
psychiatrist.
Educate the family