MORNING REPORT

Tuesday, August 5
th
2014
Patient Identity
Autoanamnesis
Name : Mr. R
Sex : Male
Age : 16 years old
Address : Tegal
Occupation : Elementary School
Marital State : Single

Alloanamnesis
Name : Ms. I
Sex : Female
Relation : Patients mother
Age : 55 years old
CHIEF COMPLAIN : PATIENT DIDN T
WANT TO EAT FOR 7 DAYS
Reason patient was brought
to emergency room
Stressor



His mother and his aunt often to
argue and fight
Present History
Patient didnt want to eat since 7 days ago
Patient has difficulty in sleeping since 15 days ago
Patient didnt want to go to school since 15 days ago
Patient often talked to himself
Day of Admission




August 5
th
2014




Patient was brought with
the reasons of:
Patient didnt want to eat
since 7 days ago
Patient has difficulty in
sleeping since 15 days ago
Patient often talked to
himself





Brought to hospital
by his mother


Social Activity Impairment
Self Care Impairment
Patient didnt want to go to school



Psychiatric History
2 years ago, patient was
hospitalized and diagnosed with
skizofrenia at RSUD Kardinah,
Tegal for 7 days. 1 year ago, patient
was recurrent, he was sent to RSUD
Kardinah, Tegal. Patient had the
medicine therapy for 2 weeks after
he went out from hospital.
Head injury (-)
Hypertension (-)
Convulsion (-)
Asthma (-)
Allergy (-)
General
medical
history
Drugs consumption (-)
Alcohol consumption (-)
Cigarette Smoking (-)
Drugs and
alcohol abuse
history and
smoking history
EARLY CHILDHOOD PHASE (0-3 YEARS OLD)
Psychomotoric
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 his hand (3-6 months)
putting everything in his mouth(3-6 months)

Psychosocial
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
Started saying words like mom or dad. (1 years old)
Emotion
His mother forgot on patients reaction when playing,
frightened by strangers, when starting to show jealousy or
competitiveness towards other and toilet training.
Cognitive
His mother forgot on which age the patient can follow objects,
recognizing her mother, recognize her family members.
His mother forgot on when the patient first copied sounds that
were heard, or understanding simple orders.
INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Psychomotor
Forgot on when patients first time playing hide and seek or if patient
ever involved in any kind of sports.
Psychosocial
Late development regarding patient psychosocial.
Communication
Forgot regarding patient ability to make friends at school and how
many friends patient have during his school period
Emotional
Forgot on patients emotional.
Cognitive
Forgot on patients cognitive.
LATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity (NO VALID DATA)
No data on when patient first experience of nocturnal emission , 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)
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 his high school period
ADULTHOOD
Educational History
He finished elementary
school.
Occupational History
He doesnt work
Marital Status
Not Married
Criminal History
No record
Social Activity
He doesnt have any friends.
Current Situation
He lives with his grandma
and uncle.
Eriksons stages
of psychosocial development
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
FAMILY HISTORY
Patient is the only child of his parents.

There were no psychiatric history in his family.

Male
Female
Has psycic disorder
Lives together
GENOGRAM
PSYCHOSEXUAL HISTORY
Patient realizes that he is a male and
interested in woman. His attitude is
appropriate as a male.
Socio-economic history
Economic scale : moderate
Validity
Alloanamnesis : valid
Autoanamnesis : valid
Symptom
Role Function
Progression of Disorder
2012 2013 2014
Mental State - August 5
th
2014
Appearance
A male, appropriate to his age, completely clothed,
poor grooming
State of Consciousness
clear
Speech
Quantity : remming
Quality : inkoheren
BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Mannerism
Automatism
Bizarre


Command automatism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia
ATTITUDE
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Cooperative
Infantile
Distrust
Labil
Rigid
Passive negativism
Catalepsy
Cerea flexibility
Excited
Emotion
Mood
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Affect
Inappropriate
Restrictive
Blunted
Flat
Labile
Disturbance of Perception
Hallucination
Auditory (+)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-) Derealization (-)
Thought Progression
Quantity

Logorrhea
Blocking
Remming
Mutism
Talk active
Quality
Irrelevant answer
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia
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
Thought of withdrawal
Thought of Broadcasting

Form of Thought

Non Realistic
Dereistic
Autism

Sensorium and Cognition
Level of education : finished elementary
school
General knowledge :High
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 : Good
Abstract thinking : Good
Ability to self care : Good

Impulse control when
examined

Self control: poor
Patient response to
examiners question:
poor
Insight

Impaired insight
Intellectual Insight
True Insight
Physical State
Consciousnes : cloudy
Vital sign :
Blood pressure : 120/70 mmHg
Pulse rate : 84 x/mnt
Temperature : 36,5 C
RR : 22 x/mnt
Review System
Head : normocephali, mouth deviation (-)
Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax :
Cor : S 1,2 regular
Lung : vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic, tympany sound
Extremity : Warm acral, capp refill <2, motoric strength
Neurological exam : not examined
Mental
Status
Impairment

Behavior: echopraxia,
stereotypy, bizarre
-Attitude: cooperative,
passive negativism
-Affect: blunted
-Thought of Progression:
remming, poverty of
speech
-Hallucination: auditorik

Patient didnt
want to eat
Patient often
talked to himself,
couldnt sleep since
7 days ago.

- Self care
impairment
- Social activity
impairment
Symptoms
Patient is a male, 16 years old, self care and social activity impairment, didnt want to
go to eat

RESUME - Day of admission
Axis I : F 20.4 Depresi Pasca-skizofrenia
Axis II : Z 03.2 no diagnosis
Axis III : no diagnosis
Axis IV : masalah dengan primary support
group (keluarga)
masalah berkaitan dengan
lingkungan sosial
Axis V : GAF scale 40-31
Multiaxial Diagnosis
Differential Diagnosis

F 25.1 Skizoafektif Tipe Depresif
PROBLEM RELATED TO THE PATIENT

Problem about patients life
oHis mother and his aunt often to argue and fight
oHe doesnt have any friends



PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)


Patient didnt want to eat for 7 days
Patient had difficulty in sleeping for 15 days
Hallucination auditorik

Response Remission Recovery
RESPONSE PHASE
Target therapy :
50% decrease of symptoms

Emergency department
Medication
Inj Diazepam 1 amp IV
Inj Lodomer 1 amp IM

Re-assess patient
REMISSION PHASE
Target therapy :
100% remission of symptom

Inpatient management
Continue the pharmacotherapy: Risperidon tab 2x3 mg
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 on his spare
time, and find a job that fits her well.)

Outpatient management
Pharmacotherapy
Psychosocial therapy

RECOVERY PHASE

Continue the medication, control to psychiatric

Rehabilitation :
- Family education
Thank you