MORNING REPORT

RSJ Prof. Dr. Soerojo

Sunday, 22nd March 2015

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

Name
Age
Religion
Address
Job
Marital status
Ethnicity
Educational status

:
:
:
:
:
:
:
:

Mr. A
43 yo
Moslem
Jagoan, Magelang
Parking attendants
Married
Javanese
Senior High School
(finished)

Alloanamnesis was conducted to :

Name : Mrs. N
Age : 55 yo
Relation : Older Sister
Address : Jagoan, Magelang

PSYCHIATRIC
HISTORY
Morning Report
Sunday, 22nd March 2014

Chief Complaint

Angry and threaten people with word.

Stressor

Unclear

History of Present Illness

1991
Patient graduated from senior high school and wanted to
continue his education in military academi. Patient passed
several test but patient couldnt make it for the final test.
Therefore, patient failed to get through in military academi.
Since then, patient had some odd behaviour, such he always
daydreaming, screamed, and angry. Patient was admitted to
the RSJSM for the first time 1993
and he had to hospitalized for 20
days.
Although his condition was better, the patient didnt work
during 2 years (1991-1993). The guardian (alloanamnesis)
said that patient routinely take his medicine during 2 years.
However, patient had some odd behaviour again, so that
patient was hospitalized (2nd time) in RSJSM for 20 days.

Cont..
1995
Patient still didnt work during 1993 until 1995. Although
patient took his medicine routinely, patient showed some
odd behaviour again, therefore patient was admitted to
RSJSM (3rd time) and hospitalized for 1 month.

2006
Patient still didnt work during 1995 until 2006. He still took
his medicine routinely. However, patient was admitted to
RSJSM (4th time) for the same reason as before and
hospitalized for about 1 month. Since then, he underwent
outpatient and took his medicine regularly. Patient had
haloperidol, chlorpromazine, and trihexylpenydyl for his
treatment

2007
Patient condition was much better so that patient married a
woman and started to work for any jobs (serabutan). Patient
still took his medicine and underwent outpatient regularly.
1 months before admission
Patient didnt take his medicine routinely as before. Since
then, patient was easy to get angry, talked and laugh by
himself when he was alone. Patient still did his job as
parking attendants but patient began to have less social
activity such worship together (pengajian) or having
conversation with some neighbours. Patient still take a bath
and eat by himself, he is doing that without command.
Patient said that he is angry because he always heard some
people always mocking at him and talking about him. He
heard that repeatedly when he was conscious and alone.

3 days before admission

the symptoms was much worse so that patient could angry
and also threaten others that he could kill them.
Day of admission
Patient is brought to the hospital by his sister because he
just threatens others again that he could kill them and
angry without any reason.
He is talking and laughing by himself when he was alone.
He said that he heard some people mocking and talking
about him. He heard that repeatedly when he was
conscious and alone.
He feels suspicious and also believes that every people is

Day of admission
While he is listening the radio, he always feels that the
radio broadcast what inside his mind and what he would do
next.
He had an excessive affection toward kyai mahmud (a
religion leader that give speech on the radio which he
listened everyday) so that he believes that he is the righthand man of kyai mahmud.

Cont..

Psychiatric illness
No information showed that patient ever
recover since the first episode (1991)
General medical illness
There is history of chronic obstructive
pulmonary disease (COPD) which needs
inhalation therapy every time he had
breathless attack
Head trauma (-) Epilepsy (-) Seizures (-)
Substance abuse
History of smoking (one pack per day)
NAPZA (-)

Family History

There is history of psychiatric illness in

patients family: patients older sister (Had
passed away)
There is no history of high fever, seizure,
head trauma, or any other serious illness
which needs hospitalization

History of Personal Life

Prenatal & Perinatal

History of pregnancy
Patient is the latest child from six
children. The pregnancy was planned.
History of birth
He was born normally at home with the
help from traditional midwife.

EARLY CHILDHOOD PHASE (0-3

YEARS OLD)
Psychomotor (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 his hand(3-6 months)
putting everything in his 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)

INTERMEDIATE CHILDHOOD PHASE (311 YEARS OLD)

Psychomotor (NO VALID DATA)
No valid data on when patients first time playing hide
and seek or if patient ever involved in any kind of sports.
Psychosocial (NO VALID DATA)
No valid data when patient child and his ability to
communicate with other people.
Communication (NO VALID DATA)
No valid data on Patients ability to make friends at
school.
Emotional (NO VALID DATA)
No valid data on patients emotional.
Cognitive (NO VALID DATA)
No valid data on patient academic history.

LATE CHILHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)
No data when patient wet dream etc.
Psychomotor (NO VALID DATA)
No valid data on patients favourite hobbies or games,
if patient involved in any kind of sports.
Psychosocial
He is easy to get angry and frustated whenever his
wish cannot be fulfilled
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
junior high school period

ADULTHOOD
Educational History
He was graduated from senior high school.
Occupational history
He began to work right after he got married. Work for
any jobs (serabutan).
Marital Status
He got married at 16 years after the first episode. He
had a boy, since then.
Criminal History
There is no criminal history

Eriksons stages of psychosocial

development
Stage
Basic Conflict
Important Events
Infancy
(birth to 18 months)

Trust vs mistrust

Feeding

Autonomy vs shame
and doubt

Toilet training

Initiative vs guilt

Exploration

Industry vs inferiority

School

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

Early childhood
(2-3 years)
Preschool
(3-5 years)
School age
(6-11 years)
Adolescence
(12-18 years)

History of Personal Life

Patient realizes that she is a male
Has interests to female
Her attitude is appropriate as a
male
SOCIO-ECONOMIC HISTORY
Economic scale : enough
VALIDITY
Alloanamnesis : valid
Autoanamnesis : valid

Genogram

Progression of Illness
Symptoms
1991
2015

Role
Function

1993

1995

2006

EXAMINATION
Morning Report
Sunday, 22nd March 2014

Physical Examination
th, 2014
Saturday, October 25th

General physical examination

General appearance
:
Good

nutritional status

Vital sign
BP

: 129/80 mmHg
HR
: 84x/m
to : afebris
RR
: 20x/m

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 : vesicular sound +/+, wheezing -/-,
ronchi-/Abdomen :
flat, abdominal wall//chest wall, normal
peristaltic, tympany sound, tenderness -, mass
-, liver, spleen and kidney not papable

Neurogical Examination

Cranial nerves examination:

CN
CN
CN
CN
CN
CN
CN
CN
CN
CN

I : in normal finding
II : in normal finding
III,IV,VI : in normal finding
V : in normal finding
VII : in normal finding
VIII : in normal finding
IX: in normal finding
X : in normal finding
XI: in normal finding
XII : in normal finding

Cont..

Physiological reflex

Pathological reflex

Upper extremities: biceps reflex (+), triceps reflex (+),

brachioradial (+)
Lower extremities: patella reflex (+), achilles tendon
reflex (+)
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski (-), chaddok (-), gordon (-),
oppenheim (-), rossolimo (-)

Motoric examination

Normal movement, good coordination, normal strength

Mental State
Examination

Appearance:

th,
Saturday, October 25th
2014

A man, appropriate to his age, completely

clothed, good self grooming

State of consciousness: clear

Speech:

Quantity : normal
Quality : normal

Cont..
BEHAVIOR

Normoactive
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy
Mannerism
Automatism
Command automatism
Mutism
Acathysia

Cont..
ATTITUDE

Non-cooperative
Cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Infantile
Labile
Rigid

Cont..
EMOTION

MOOD
Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed

AFFECT
Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of
Perception

Cont..

Hallucination
Auditory (+)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)

Illusion
Auditory (-)
Visual (-)
Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)

Depersonalization (-)

Derealization (-)

Thought
Progression

Quantity
Logorrhea
Blocking
Remming
Mutism
Talkative

Cont..
Quality
Coherent
Irrelevant answer
Coprolalia
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigeration
Perseveration
Sound association
Word salad
Echolalia

Content of
Thought
Idea of Reference

Idea of grandiose
Preoccupation
Obsession
Phobia
Fantasy
Delusion of
Persecution
Delusion of Reference
Delusion of Envious
Delusion of
Hypochondriac
Delusion of Magicmystic

Cont..

Delusion of
Grandiose
Delusion of Control
Delusion of Religion
Delusion of Influence
Delusion of Passivity
Delusion of Perception
Delusion of
Suspicion
Thought of Echo
Thought of Insertion &
withdrawal
Thought of
Broadcasting

Cont..
Form of Thought

Realistic
Non Realistic
Derealistic
Autism
Cannot be evaluated

Sensorium and Cognition

Level of education : finished senior high school

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 : good
Abstract thinking: good
Ability to self care : good

Impulse control when

examined
Self control: good
Patient response to examiners
question: good

Insight
Impaired insight
Intellectual Insight
True Insight

RESUME
Morning Report
Sunday, March 22nd, 2014

A man, 43 years old, married, employed, easily getting angry,

threatens others, change in behavior, irritable, suspicious
Symptom:

Mental Status:

Impairment:

Angry without any reason and

threaten people that he could kill
them
Talk and laugh by himself when
he was alone
Less social activity than before
such worship together
(pengajian) or having
conversation with some
neighbours
Patient still take a bath and eat
by himself, and doing it without
any command
Heard some people mocking and
talking about him. He heard that
repeatedly when he was
conscious and alone
feels suspicious and also believes
that every people is badmouthing
behind his back

Affect :
inappropriate,
Restricted
Progression of
Thought: talkactive,
Content of thought
: Thought of
broadcasting,
Delusions of
suspicious,
Delusions of
grandiose
Form of thought :
Non-realistic

Patient
decreased
socializatio
n

Symptom:

Mental Status:

Impairment:

he believes that he is the righthand man of kyai mahmud

didnt take his medicine routinely
as before
He has some episode of
breathless attack which needa an
inhalation treatment every
month

Perception :
Hallucination
Auditorik (+)
Insight: Impaired
insight

Patient
decreased
socializatio
n

DIAGNOSIS
Morning Report
Sunday, 22nd March 2014

Thought of broadcasting
Auditoric Hallucination
Affect restricted, Inappropriate
Non-Realistik Form Thought
Impaired Insight
Delusions of suspicious

Delusions of grandiose

Syndrome
Schizophreni
a
Syndrome
Schizofrenia
Paranoid
Syndrome
Mania

Differential Diagnosis

F20.0 Paranoid Schizophrenia

F25.0 Maniac-Type of Schizoafective
Disorder

Multiaxial Diagnosis

Axis I

: F20.0 Paranoid Schizophrenia

Z91.1 Treatment adherence
Axis II : F60.0 Paranoid Personality
Disorder
Axis III : J00-J99 Respiratory Disease
Axis IV : Educational and Psikososial
Problem
Axis V : GAF admission 60 51

MANAGEMENT
Morning Report
Sunday, March 22nd, 2014

Management Planning

Hospitalized
Pharmacotherapy

Emergency Department Inj. Haloperidol 5

mg IM
Maintenance

Psycho-education

Response

Remiss
ion

Recove
ry

Response Phase

Target therapy :
50%

decrease of symptoms

Maintenance
Risperidone

2 dd 2 mg PO
Haloperidol 50 mg IM every 2 weeks

Re-assess patient

Remission Phase

Target therapy :
100% remission of symptom
Inpatient management
Risperidone 2 mg PO 2dd1
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)
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

Thank You!

Sunday, March 22nd 2015