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MORNING

REPORT
Monday, September 29th
2014

SUPERVISOR
dr. Sabar P. Siregar, S

PATIENTs IDENTITY
Name
: Mr. L
Sex
: Male
Age
: 68 years old
Address
: Wonosobo
Occupation
: Head Master of
Religious School
Marital State
: Married

Alloanamnesis
I

II

Age

65 years old

36 years old

Sex

Female

Male

Address

Wonosobo

Wonosobo

Job

House wife

Merchant

Elementary School

Senior High School

Relationship

wife

Son

Duration of
relationship

45 years

36 years

Strength of
relationship

Strong

Strong

Name

Educational status

The Reason Patient was


Brought to Emergency Room
Patient has been :
Patient gets angry easily
Patient often becomes raged
Patient deliberately destroys household
Patient talks to himself

STRESS
OR

Family problem involving conflict


between wife and daughter in law

DAY OF ADMISSION

CURRENT PSYCHIATRIC HISTORY

History of Personal Life


Prenatal and perinatal
Patients mothers health during
pregnancy is not known.
Patient was born in his house and was
assisted by traditional birth attendant.
Patients history of complete
immunization is not known

History of Personal Life

Early childhood phase (0-3 years old)


Psychomotor

There was no delay in other psychomotor aspect (such as


tilting the body, supine to prone, sitting, standing, smiling,
holding his own hand, scoop up object, holding pencil and
pilling up two objects)
Psychosocial
There was no delay in psychosocial aspect (such as replying to
smile, smiling when seeing interesting object, playing cilukba,
knowing his family members and pointing what she wanted without
crying)

Communication
There was no delay in communication aspect (such as bubbling,
cooing, making sounds without meaning, telling 2-3 syllables
without meaning and calling mama/papa)

Emotion
There was no delay In emotion aspect (such as when patient
playing, frightened by strangers, starting to show jealousy or
competitiveness towards other, and toilet training)
Patient didnt pee or defecate in her pants when he was two years
old

Cognitive
There was no delay in cognitive aspect (such as copying sounds
that he heard for the first time and understanding 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 or if patient ever involved in any kind
of sports.

Psychosocial
No available data about his interaction with friends
around him

Communication
Patient didnt have any trouble to communicate with
others (such as introducing himself and talking with
others)

Emotion
No available data about the nature of the patients
emotions.

Cognitive
Patient went to elementary school at 5 years
old and was an average student.

History of Personal Life

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


Psychomotor

No valid data if patient had any favorite hobbies or


games, if patient involved in any kind of sports.

Psychosocial
Patient was an extroverted boy and had many
friends

Communication
Patient didnt have any trouble to communicate with
others (such as introducing himself and talking with
others)

Emotion
No valid data if patient was an emotional person.

Cognitive
After graduating from elementary school, patient
continued to study to at pesantren

History of Personal Life

Adulthood phase (18 years old-now)


Educational
Patient graduated from elementary school and went to
pesantren there on.

Occupational
Patient has a history of being the Kades. He is the
headmaster of the pesantren he owns and runs
Marital status
Patient got married when he was around 23 years old

Criminal
Patient has no criminal history
Social activity
There was no abnormalities in patient social activity before patient
got sick. Patient was extroverted and had many friends

Current situation

Patient lives with his wife.

Eriksons stages of psychosocial


development

History of Personal Life


Psychosexual history and sexual development
Patient realizes that he is a male, and interested in
female. His attitude is appropriate as a male.
Patient was taught to be a male and played with his
male peers.
Patients history of dating is not known.
Patients first experience of wet dream is not known.
Socioeconomic history
Currently the patient is unable to perform as the
headmaster
Economic scale : moderate
Degree of validity : valid

FAMILY HISTORY
Patient is the 1st child from 8
siblings

No psychiatric history in the family

Genogram

PSYCHOSEXUAL
PatientHISTORY
realizes that he is

male
Is interested in females
His attitude is appropriate as
a male

Progression of Disorder
Symptom

1
3

Role Function

1
4

MENTAL STATE

Mental State

29th September 20

BEHAVIOUR
Normoactive
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active
negativism
Cataplexy
Streotype
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
Stereotype
Catalepsy
Cerea flexibility
Excited

EMOTION

DISTURBANCE OF
PERCEPTION

Depersonalization (-)

Derealization (-)

THOUGHT PROGRESSION

CONTENT OF THOUGHT

Delusion of grandiose

Idea of Reference

Idea of Guilt

Preoccupation

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

Delusion of Control
Delusion of Influence
Delusion of Passivity

FORM OF THOUGHT
Non Realistic

Dereistic
Autism
Cannot be evaluated

SENSORIUM AND
COGNITION

Level of education
: Graduated from
pesantren
General knowledge
: good
Orientation of time
: good
Orientations of place
: good
Orientations of people
: good
Orientations of situation
: good
Working/short/long memory
: good
Writing and reading skills : good
Visuospatial
: not assessed
Abstract thinking
: not assessed
Ability to self care
: good

PHYSICAL STATE
Consciousnes : compos mentis E4
V5 M6
Vital sign
Blood pressure
mmHg
Pulse rate
Temperature
RR
x/mnt

: 168/106
: 96 x/mnt
: Afebrile
: 22

REVIEW SYSTEM
Head

: normocephali, mouth deviation (-)

Eyes

: anemic conjungtiva (-), icteric

sclera (-), pupil


Neck

isocore

: normal, no rigidity, no palpable

lymph nodes
Thorax
Cor

: S 1,2 regular

Lung : vesicular sound, wheezing -/-,


ronchi-/ Abdomen

: Pain (-) , normal peristaltic,

RESUME
Symptom:
Patient gets angry easily, becomes raged, deliberately
destroys household, talks to himself

Mental Status:

Behavior: hyperactive
Attitude: distrust
Mood: elevated
Affect: blunted
Content of thought: idea of reference, preoccupation
Progression of thought: logorrhea, irrelevant answer

Impairment:
Patient cant do the occupation
Patient has a poor utilization of his leisure time
Impairment of social function

DIFFERENTIAL
DIAGNOSIS
F20.2 Catatonic Schizophrenia
F23.1 Acute Polymorphic Psychotic
Disorder with Schizophrenic
Symptoms

MULTIAXIAL
DIAGNOSIS
Axis I
: F20.2 Acute
Polymorphic Psychotic
Disorder with
Schizophrenic Symptoms
Axis II
: Z03.2 No diagnosis
Axis III
: Hypertension stage
2 (under
medication)
Axis IV
: Stressor from
conflict between wife
and
daughter in law
Axis V
: GAF admission 20-11

Problem Related to The


Patient
1.Problem about patients psychological state
Patient is bothered by the decrease in enrollment of his
religious school. His medical condition is holding him back from
doing what he enjoys i.e to teach. The outstanding conflict
between his wife and daughter in law has affected him
immensely as it has caused his son to leave the house with his
wife.
2. Problem about patients biological state
Patient has a history of trigeminal neuralgia. His current
condition is due to the overactivity of neurotransmitters in his
brain.
-

Problem Related to The


Patient
3.Problem about patients social being
Patient has withrawn himself from the people
around him. He no longer conducts pengajian tends
to live in his own world

Management Planning
Hospitalization
- Patient has impaired function and he is becoming
a nuiscance to the family and neighbourhood
Emergency Department
Haloperidol 5mg im (To reduce positive symptoms)
Diazepam 5 mg iv
(To sedate and relax the muscles)
-captopril 3x25 mg p.o

Wards
Haloperidol 5 mg po 2dd1 (To decrease in positive
symptoms)

Psychotherapy

Response Phase
Target therapy :
50% decrease of symptoms
Emergency department
Diazepam inj 5 mg iv (To sedate and relax
muscles)
Maintenance
Haloperidol 5 mg po 2dd1 (To reduce positive
symptoms)
Re-assess patient

Remission Phase

Target therapy :
100% remission of symptom

Inpatient management
Risperidone 2mg 1ddI (Atypical antipsychotic for long term
treatment and reduce in side effects)
Improving the patient quality of life :
Teach patient about his social & environment (interact with his
family, socialize with his neighbor or friends, find a hobby to do in
his spare time)

Outpatient management
Pharmacotherapy
Psychosocial therapy

Recovery Phase
Continue the medication, control to
psychiatric
Rehabilitation :
- Help patient to find a hobby,
- Help patient to interact normally with
his family and neighbor
- Family education