Morning Report

Friday January 9th , 2015

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

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mrs. N
: 46 years old
: female
: Kejajar Wonosobo
: Farmer
: married
: Javanese
: Elementary School

Identity
Alloanamnesis was conducted to :
1.
2.
3.
4.
5.
6.
7.
8.

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mrs. B
: 25 years old
: female
: Kejajar Wonosobo
: Housewife
: married
: Javanese
: Elementary School

Chief Complaint
Strange behavior

History of Present Illness

5 months before patients admission
Patient locked herself in her room, refuses to talk.
She only eats a little food, Isolate herself, rarely taki
ng bath, refuses to do everything. She looks scare
d, sad, and anxious.
At september, her family already took her to Puske
smas and RSUD Wonosobo but the doctor said tha
t there is no significant illness, just too much stress
or.
She rarely work in the ricefield, limiting his socialica
tion with family and neighbour.

History of Present Illness

1 month before patients admission
Patient often talk to herself, gigling, sometimes c
annot fall asleep, standing all night long in the fr
ont of door because she is forbade to go out by h
er family. Strated to talk incoherently. Defecating
and urinating on the spot. She has to be insisted
to take a bath. Wandering inside the house. Eat e
xcessively, but need to be prepared. Crying when
she didnt get what she wanted.

The day of admission

Her family concerned with her condition and br

ought him to RSJ Soeroyo Magelang.

History of Past Illness

Psychiatric illness

There is no history of pcychiatric illness.

General medical illness
There is no history of high fever, seizure, h
ead trauma, or any other serious illness wh
ich needs hospitalization
Substance abuse
There is no history about alcohol use or s
moking .

Depiction of Illness
Symptoms

August 2014

Role
Function

January 2015

Family History
There is no history of psychiatric illnes

s in her family.
There is no history of high fever, seizu
re, head trauma, or any other serious il
lness which needs hospitalization

GENOGRAM

History of Personal Life

Prenatal and perinatal
There was no valid data in patients prenat

al and perinatal aspect, such as :

Patients mothers age and condition whe
n she was pregnant
Patients mothers delivery history and pat
ients perinatal condition.
Patients immunization status

History of Personal Life

Early childhood phase (0-3 years old)
Psychomotor

There was no valid data in patients psychomotor aspect (such as tilting the body,

supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop
up object, holding pencil and pilling up two objects)

Psychosocial
There was no valid data in patients psychosocial aspect (such as replying to smile,

smiling when seeing interesting object, playing cilukba, knowing her family memb
ers and pointing what she wanted without crying)

Communication
There was no valid data in patients communication aspect (such as bubbling, cooi

ng, making sounds without meaning, telling 2-3 syllables without meaning and ca
lling mama/papa)

Emotion
There no valid data in patients emotion aspect (such as when patient playing, frig

htened by strangers, starting to show jealousy or competitiveness towards other,

and toilet training)
Patient didnt pee or defecate in her pants when she was two years old

Cognitive
There was no valid data in patients cognitive aspect (such as copying sounds that

she 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 s

eek or if patient ever involved in any kind of sports.

Psychosocial
No valid data

Communication
No valid data

Emotion
No valid data

Cognitive
No valid data.

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

No valid data
Communication
Patient didnt have any trouble to communicate with others

(such as introducing herself and talking with others)

Emotion
No valid data

Cognitive
After graduating from elementary school, patient did not go

to school anymore

History of Personal Life

Adulthood phase (18 years old-now)
Educational
Patient graduated from elementary school

Occupational
Patient had work ricefield

Marital status
Patient has got married.

Criminal

He has no criminal history

Social activity

Patient was an a ricefield and a housewife so she just stayed

at home and taking care of her children. Patient sometime i

nteracted with neighbour
Current situation

Patient lives with her husband and 3 children.

History of Personal Life

Psychosexual history and sexual development
Patient had menstruation when she was 11 years old
Patient realizes that she is a girl, and interested in male.

Her attitude is appropriate as a girl.

Patient was taught to be a girl and played with her friend
s
Socioeconomic history
Patient doesnt have any job now
Economic scale : low
Degree of validity : valid

Eriksons stages of psychosocial development

Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

Autonomy vs shame
and doubt

Toilet training

Initiative vs guilt

Exploration

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

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)
Preschool
(3-5 years)
School age
(6-11 years)

Maturity
(65- death)

Examination
Morning Report
Thursday January 8th , 2015

Physical Examination
Morning Report
Thursday January 8th , 2015

General physical examination

General appearance :
She looks in mild illness

Vital sign
:
BP : 120/70 mmHg
HR : 100x/m
to : afebris
RR : 20x/m

General physical examination

Head :
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
Neck : normal, no rigidity, no palpable lymph nodes
Thorax
Cor

Lung

:
: S1 S2 regular, murmur -, gallop
: vesicular sound +/+, wheezing -/-, ronchi-/-

Abdomen

flat, abdominal wall//chest wall, normal peristaltic, tympany sound, t

enderness -, mass -, liver, spleen and kidney not papable

Extremity

: Warm acral, capp refill <2, edema (-)

Neurological examination
Level of Consciousness :
compos mentis, E4V5M6 (15)

General Appearance :
Body posture : normal
Abnormal movement : Walking style : abnormal

Neurological examination
Cranial nerves examination:
CN I
CN II

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

Neurological examination
Motoric
Upper extremities: tonus (+), trophy : eutrophic, power of movem

ent : shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve f

unction : 5, ulnar nerve function : 5, median nerve function : 5
Lower extremities: tonus (+), trophy : eutrophic, power of movem
ent : hip joint : 5, knee joint : 5, ankle joint : 5

Sensorium
DCML system : proprioception, fine touch : no abnormalities
AL system : vibration, temperature, crude touch, pain : no abnorm

alities

Neurological examination
Physiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+), brachioradi

al (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)
Pathological reflex
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski (-), chaddok (-),gordon (-),oppenhei

m (-), rossolimo (-), clonus -/Meningeal sign

Neck stiffness (-), brudzinski neck sign (-), brudzinski contralateral

leg sign (-), kernig sign (-)

Cerebellum function
Adhyadokokinesia (-), romberg test (-), finger to nose test (no ab

normalities), tip to toe walk (no abnormalities)

Mental State Examination

Morning Report
Thursday January 8th, 2015

General Appearance
A woman, age 46 years old, appro
priate to her age, poor self groomi
ng

Photo

Orientation
Time : poor
People : good
Place : poor
Situation : poor

Consciousness

Clear

Behavior

Hypoactive

Hyperactive

Echopraxia

Catatonia

Active

negativism

Cataplexy

Streotypy

Mannerism

Automatism

Bizzare

Command

automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor

Compulsive

Ataxia

Mimicry

Aggresive

Impulsive

Abulia

agitation

Attitude

Non-cooperative

Indiferrent

Apathy

Tension

Dependent

Passive

Infantile

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy

Cerea flexibility

Excited

Emotion
Affect

Mood

Dysphoric
Depressed
Euthymic
Elevated
Euphoria

Anxiety
Irritable
Agitation

Inappropria
te

Broad
Restrictive
Blunted
Flat
Labile

Disturbance in Perception
Hallucination

Auditory (+)
Visual (+)

Olfactory (-)
Gustatory (-)
Tactile (-)
Somatic (-)
Depersonalization (-)

Illusion

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

Derealization (-)

Progression of Thought
Quantity

Quality
Irrelevant answer

Logorrhea
Blocking
Remming
Mutism

Talkative

Coprolalia

Incoherence

Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangentiality
Verbigration
Perseveration
Sound association
Word salad
Echolalia

Content of Thought

Idea of Reference

Delusion of Grandiose

Preoccupation

Delusion of Control

Obsession

Delusion of Religion

Phobia

Delusion of Influence

Fantasy

Delusion of Passivity

Delusion of Persecution

Delusion of Perception

Delusion of Reference

Idea of Suspicion

Delusion of Envious

Thought of Echo

Delusion of Hypochondriac

Thought of Insertion &

Delusion of Magic-mystic

Idea of suicidal

withdrawal
Thought of Broadcasting

Form of Thought
Non Realistic
Dereistic
Autism
Cannot be evaluated

Recording Clip

Cognitive Function
Level of education

: finished elementary school

General knowledge
: poor
Working/short/long memory: poor
Writing and reading skills : good
Visuospatial
: good
Abstract thinking
: poor
Ability to self care : poor

Impulse Control When Examined

Self control: good
Patient response to examiners question: poor

Insight
Impaired insight
Intellectual Insight
True Insight

Resume
Morning Report
Thursday January 8th, 2015

Resume
Symptom:
she locked herself in her room
refuses to talk
only eats a little food
Isolate herself
rarely taking bath
refuses to do everything
looks scared, sad, and anxious
Defecating and urinating on the spot
Wandering inside the house
Eat excessively, but need to be prepared
Crying when she didnt get what she wanted.

Mental Status:
Behavior : normoactive
Mood : anxiety
Affect : innapropriate
Content of thought :obsesive
Form of thought : non realistic

Impairment:
Patient cant socialize with others
Patient has poor self grooming
Patient cant work

Diagnosis
Morning Report
Friday January 9th, 2015

Differential Diagnosis
F20.2 Schizophrenia catatonic
F20.4 Post Depression Schizophrenia

Multiaxial Diagnosis
Axis I : F20.2 schizophrenia catatonic
Axis II: R46.8 delayed axis II diagnosis
Axis III
Axis IV
Axis V

: no diagnosis
: psikososial problem
: GAF admission 30-21

Management
Morning Report
Friday January 9th, 2015

Patients problems
Biological problem
Positive symptoms because of an increase in dopa

mine amount in the post synaptic neuron

Psychological problems
She is deceived by a married man

Social problem
she verbally bullied by her neighbor
she cant socialize well with others

Management Planning
Hospitalization
Patient was hospitalized because
She isolate her self in the room, talking to herself, gigglin
g and bad hygiene.

After that, were planning for response, remissi

on and recovery phase for this patient

Response Phase
Target therapy :
50% decrease of symptoms
Emergency department
Diazepam Inj 5 mg IV (for its sedative and muscle rela

xation effect)
Haloperidol Inj 5 mg IM (to reduce positive symptoms)

Maintenance
Suggest ECT
Risperidone Tab 2x2 mg PO (to reduce positive sympt

oms)

Re-assess patient

 Target therapy :
100% remission of symptom

Inpatient management
Risperidone Tab 2x2mg PO (to reduce the positive symptom an

d decrease the possibilities of side effect)

Improving the patient quality of life :
Teach patient about her social & environment (interact with her fami

ly, socialize with her neighbor or friends, find a hobby to do on her s

pare time)

Outpatient management
Continuation of pharmacotherapy
Psychosocial therapy

Recovery Phase
Continue the medication, control to psyc

hiatrist
Rehabilitation :
Consult to psychologist to help patient f
inding a hobby
Help patient to interact normally with h
er family and neighbor

Family Education
Explain to the family that anyone could have mental disorders
Mental disorders are caused by multifactorial factor, not only

by genetic inheritance
Mental disorders mostly are affected by chemical imbalance i
n brain
Mental disorders can be controlled by medicines, so it is impo
rtant to take the medicines routinely
Treat patient like you treat any other people
Help patient if she should be helped
Dont push patient to understand the family, but her family th
at has to understand her
Dont be too emotional to patient

Thank You!
Friday january 9th , 2015