Monday , November 24th 2014

MORNING REPORT
Supervisor :
dr. Sabar P Siregar Sp.KJ

Patients Identity

Name
: Mr. Qoimun
Age
: 34 years old
Gender
: Male
Address
: Delok Kidul 2/5 Munglid Magelang
Occupation
: Seller
Marriage Status : unmarried
Religion
: Islam
Last Education : Elemantary School

Alloanamnesis
Guardian
Name : Mr. Haryanto
Age
: 50 years old
Relation : Uncle

Complaint
Patient

is brought to the hospital by

her uncle due to his nephew was try
to suicide three times.

Stressor
He

always keep his feeling to woman and he

never tell her about his feeling
The patients father had died and his mother
worked as a housekeeper, and the patient had
stopped working as a trader sandals

Progression of illnes
M

5 days before admission

Present Illness

Psyciatry History
Medication
Trauma
Patient had been banging his head repeatedly against
the wall
Drugs and alcohol abuse history and smoking history
- Alcohol consumption (-)
- Tobacco consumption (-)
- Drug use (-)

History of Personal Life

1.

Prenatal and Perinatal History

2.

Early childhood phase

3.

Intermediate childhood

4.

Late childhood

5.

adulthood

Prenatal and Perinatal

history
Her uncle did not know about any medical
condition during pre and perinatal (no valid
data).

Developmental History (Gross Motoric)

Result

Ability

Normal range

Elevating the head

Normal

0-3 months

Moving to supine
position on its own

Normal

3-6 months

Sitting

Normal

6-9 months

Standing

Normal

9-12 months

Walking

Normal

12-24 months

Climbing up the
ladder

Normal

24-36 bulan

Standing 1 foot / jump Normal

36-48 bulan

Developmental History (Fine

Motoric)
Ability

Result

Normal range

Holding a pencil

Normal

3-6 months

Holding 2 objects at the same

time

Normal

6-9 months

Piling 2 cubes

Normal

9-12 months

Inserting objects into container

Normal

12-18 months

Rolling a ball

Normal

18-24 months

Doodling

Normal

24-36 months

Wearing shirt

Normal

36-48 months

Developmental History
(Language)
Ability

Result

Normal range

Oooh-aah

Normal

0-3 months

Turning toward the sound

Normal

3-5 months

High-pitched sound

Normal

3-6 months

Voice without meaning (mamama,

Bababa)

Normal

6-9 months

Calling 2-3 syllables without meaning Normal

9-12 months

Calling 3-6 words that have meaning

Normal

18-24 months

Talking at least with two words

Normal

24-36 months

Mentioning name, age, and place

Normal

36-48 months

Developmental History (Social & Personal)

Ability

Result

Normal range

Know their mother

Normal

0-3 months

Reach out

Normal

3-6 months

Clap

Normal

6-9 months

Playing peek a boo

Normal

6-9 months

Know their family

Normal

9-12 months

Appoint what he wants without

crying or whining

Normal

12-18 months

Tidy up toys

Normal

24-36 months

Playing with friends, follow the

rules of the game

Normal

36-48 months

Intermediate Childhood (3-11 years

old)
Psychomotor

(NO VALID DATA)

No valid data on when patient first time climbing the tree or play hide and
seek games, and if patient ever involved in any kind of sports.
Psychosocial (NO VALID DATA)
There were no valid data on patients gender identification, interaction with his
surrounding
There were no data on when patient first entered primary school, how well
patient handle separation from parents, how well he plays with new friendson
first day of school
Communication

(NO VALID DATA)

There were no valid data regarding patients ability to make friends in
school, and how many friends patient have during his schooling period.
Emotion (NO VALID DATA)
No valid data on patient adaptation under stress
Cognitive (NO VALID DATA)
No valid data on patients grades in school

Late Childhood and Teenage

Phase

Sexual

Development Sign and Activity (NO VALID DATA)

No data on when patient experience wet dream, growth hair on armpits,
growth pubic hair, 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 on when and how patients relationship with different gender, if
patient ever had any relationship with opposite gender.
Communication

(NO VALID DATA)

No valid data on how well the relathionship between patient with parents
and other family.
Emotion (NO VALID DATA)
No data if patient ever told friend or family regarding any problems
No data if patient attempted to break the rules (truant school subject, fight
with friends, bullying, ect) and consuming alcohol, smoke and drugs

Preschool
Physical

Cognitive

Physically active

Ego-centric, illogical,
magical thinking

Rule of three: 3 yrs, 3 ft,

33 lbs.

Explosion of
vocabulary ; learning
syntax, grammar ;
understood by 75 % of
people by age 3

Weight gain : 4-5 lbs per

year
Growth : 3-4 inches per
year
Physically active, cant
sit still for long
Clumsy throwing balls

Social
Play :
Cooperative,
Imaginative, may
involve fantasy and
imaginary friends, takes
turn in games

Develops gross and fine

motor skills ; social
Poor understanding of
skills; experiment with
time, value, sequence of social roles ; reduces
events
fears
Vivid imaginations ;
some difficulty
separating fantasy from
reality
Accurate memory, but

Wants to please adults

Refines complex
skills : hopping,
jumping, climbing,
running, ride big
wheels and
tricycles
Improving fine
motor skills and
eye-hand
coordination: cut
with scissors, draw
shapes
3 3 yr : most
toilet trained

Primitive drawing,
cant represent
themselves in
drawing till age 4

Development of
conscience;
incorporates
parental
prohibitions; feels
Dont realize others guilty when
have different
disobedient;
perspective
simplistic idea of
good and bad
Leave out important behavior
facts
Curious about his
May misinterpret
and others bodies,
visual cues of
may masturbate
emotions
No sense of privacy
Receptive language
better than
Primitive,
expressive till age 4 stereotypic
understanding of
gender roles

Emotional

Possible effects of maltreatment

Self- esteem based on

what others tell him or
her

Poor muscle tone, motor coordination

Increasing ability to
control emotions; less
emotional outbursts

Cognitive delay : inability to concentrate

Increased frustation
tolerance
Better delay
gratification
Rudimentary sense of
self

Poor pronunciation, incomplete sentences

Cannot play cooperative : lack curiosity, absent imaginative

and fantasy play
Social Immaturity; unable to share or negotiate with peers;
overly bossy, aggressive, competitive
Attachment problems : overly clingy, superficial
attachments, show little distress or over-react when
separated from caregiver
Underweight from malnourishment : small stature

Understands concepts
of right and wrong
Self-esteem reflects
opinions of significant
others

Excessively fearful, anxious, night terrors

Reminders of traumatic experience may trigger severe
anxiety, aggression, preoccupation
Lack impulse control, little ability to delay gratification

Curious
Self-directed in many

Exaggerated response (tantrums, aggression) to even mild

stressors

Adulthood

Educational History
Elementary School

Marriage Status
unmarried

Social Activity
Normal interaction

Occupational History
Seller

Current Situation
Live with his mother

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

Conclusion: no clear data

History

Genogram

Socio-Economic History
Economic Scale : Poor. The patients
father had died and his mother worked as a
housekeeper, and the patient had stopped
working as a trader sandals

Validity
Alloanamnesis
Autoanamnesis

: Valid Data
: Valid Data

PROGRESSION OF ILLNESS
Symptom

May 2014

Role of Function

Nov
2014

Mental State
(November, 24th 2014)
Appearance

A Male, appropiate to his age, wear

complete clothes, poor self grooming.
State

of Consciousness

Clear
Speech

- Quantity : Decrease
- Quality : Decrease

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy

Mannerism
Automatism
Bizarre
Command
automatism
Mutism
Acathysia
Tic
Somnabulism

Psychomotor
agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

ATTITUDE
Cooperative
Non-cooperative
Indiferrent
Apathy
Tension
Dependent

Infantile
Distrust
Labile
Rigid

Passive
negativism
Catalepsy
Cerea flexibility
Excitement

Emotion
Mood

Dysphoric
Elevated
Euphoria
Expansive
Irritable
Cant be assesed

Affect

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Disturbance of Perception
Hallucination
Auditory (+) heard the

voice repeated in his

ear
Visual (+) seeing
himself is a demon in
the form of
genderuwo

Olfactory (+) smell the

faeces but there is no

faeces in the surrounding

Gustatory (-)
Tactile (-)
Somatic (-)
Undeferrentiated (-)

Depersonalisation (-)

Illusion

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

Derealisation (-)

Thought Progression
Quantity

Logorrhea
Blocking
Remming
Mutisme
Talkative

Quality

Irrelevan answer
Incoherence
Flight of idea
Confabulation
Poverty of speech
Slow speech
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigrasi
Perseverasi
Sound association
Word salad
Echolalia

Content of thought
Idea

of Reference

Delusion of Grandiose

Preocupation

Delusion of Control

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Delusion

of Persecution

Delusion of Perception

Delusion

of Reference

Thought of Echo

Delusion

of Envious

Thought Insertion

Delusion

of Hipochondry

Thought of withdrawal

Delusion

of magic-mystic

Thought Broadcasting

Fantasy

Cant be assesed

Form of Thought
Realistic
Non Realistic
Dereistic
Autistic

Sensorium and Cognition

Level of education
: Low
General knowledge
: Low
Orientation of time/
place/people/situation : Good/good/good/good
Working/short/long memory: Poor/good/good
Writing and reading skills : good
Ability to self care
: poor

Impulse Control When Examined

Self control : Average.
Patient response to examiners
question: Poor.

Insight
Impaired insight (patient do not
know he is mentally ill)
Intelectual Insight
True Insight

Physical examination
Conciousness
Vital

: composmentis

sign:

- Blood pressure : 140/100 mmHg

- Pulse rate
: 84 x/min
- Temperature : 36,2
- RR
: 20 x/min

Skin
: rash(-), petechiae (-)
Head
Eye : conjunctival pallor (-), yellowish sclera (-)
Nose : discharge(-), nasal flare (-)
Ear : discharge(-)
Mouth : within normal limit
Neck : lymphnodes within normal limit
Lungs : symmetrical, retraction(-), vesicular (+/+),
abnormal lung sounds (-/-)
Heart : S1, S2 regular, murmur(-), cardiomegaly
(-)
Abdomen : Supple, tympany (+), Distention (-),
Hepatomegaly (-), Splenomeogaly (-)

Neurological Status

Motorik : Normotonus, good coordination of

movement

Meningeal sign : negative

Physiologic reflex : +/+

Patologic reflex : -/-

Significant Finding Resume

Onset

: 6 months ago

Symptoms
The patient felt sad,
guilty, and often
daydream. Patient had
been banging his
head repeatedly
against the wall.
The patient had
attempted suicide 3
times because he
feels worseless living
his live and always
feel guilty

Mental status
Mood: dysphoric
Affect: appropriate,
Disturbance of
perception:
hallucination of
auditory(+), visual
(+), olfactory (+)
Tought progression:
- Quality: Poverty of
speech, slow speech
- Quantity: Remming
Content of tought :
Delusion of
hypocondric, delusion
of magic-mystic
Form of tought: Non
realistic

Impairment

Rarely to take a
bath
Lazy to work
Limited social
interaction
Tentamen
suicide

Differential diagnosis
F32.3 Psychotic features associated with severe

depression
F25.1 Schizoaffective Depression Type

Multiaxial Diagnose
Axis I : F32.3 Psychotic features associated with severe depression
Axis II : Z.03.2 none
Axis III : none
Axis IV : He always keep his feeling to woman and he never tell her
about his feeling, The patients father had died and his mother worked
as a housekeeper, and the patient had stopped working as a trader
sandals
Axis V : GAF admission 20 11

PROBLEM RELATED TO THE

PATIENT
1. Problem about patients life (social)
He always keep his feeling to woman and he never tell her about
his feeling,
Economy : poor,
The patients father had died and his mother worked as a
housekeeper, and the patient had stopped working as a trader
sandals
2. Problem about patients biological state (biology)
There were abnormality imbalance neurotransmitter, hyperactivity
of serotonin and dopamine.

3. Problem about patients mental state (psychology)

Auditory , Visual, Olfactory hallucination , Dellusion of Magic-Mystic

PLANNING MANAGEMENT

PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
Tentamen Suicide
Auditory , Visual, Olfactory hallucination
Waham magic-mystic

Emergency department
Inj. Diazepam 1 ampule IV
Inj. Haloperidol 1 ampule IM

RESPONSE PHASE
Target therapy :
50% decrease of symptoms
Maintenance
Amitriptylin tab 3 x 25 mg/ day
Inj. Haloperidol 1 ampule IM

REMISSION PHASE

Target therapy :
- 100% remission of symptom

Inpatient management
- Continue the pharmacotherapy:
Amitriptylin tab 150 mg/day
Inj. Haloperidol 1 ampule IM

- Improving the patient quality of life :

Teach patient about her social & environment (interact with
her family, socialize with her neighbor or friends, find a hobby
to do on her spare time)
Outpatient management
- Pharmacotherapy

RECOVERY PHASE
Continue the medication, control to psychiatric
Rehabilitation :
- Help patient to interact normally with her
family, friends, and neighbor
- Do some activities that can keep patient
occupied
- Family education

TERIMA KASIH