MORNING REPORT

Sunday, October 26th, 2014

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

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mr. P
: 52 years old
: Male
: Barang Wetan
: Farmer
: Married
: Javanese
: Junior High School

Identity
Alloanamnesis was conducted to :
I
Name

Age

48 years old

Sex

Female

Address
Job
Relationship
Strength of relationship

Barang Wetan
Housewife
Wife
Strong

Morning Report
Sunday, October 26th, 2014

PSYCHIATRIC HISTORY

Chief Complaint
Wandering around and not coming home.

Stressor
Unknown

History of Present Illness

1 Week Ago
The patient prayed from night to early morning and fell
asleep. After he woke up, he told his wife that he had a
dream that told him to opened a grave in his village.
Then, he and some of villagers came to the location in
his dream but there was nothing but a garden there. He
came back home and started to locked himself in the
room. He read Al-Quran and talked randomly by
himself. He only left his room to eat and take a bath. He
didnt go to work.

Contd
1 Days Ago
The patient tried to killed himself with knive but it can
be prevented by his brother. He couldnt sleep at night
and he was wandering around outside his house and
found in a police station in the next morning.

History of Past Illness

Psychiatric illness
There is no history of psychiatric ilness

General medical illness

There is no history of high fever, seizure, head trauma, or any other

serious illness which needs hospitalization

Substance abuse
History of smoking
No history of use of alcohol and drugs

Depiction of Illness
Symptoms
2014

Role
Function

Family History
There is no history of psychiatric illness in patients family

There is no history of high fever, seizure, head trauma, or

any other serious illness which needs hospitalization

Genogram
Description

: man
: woman
: death
: patient

History of Personal Life

Prenatal
History of pregnancy
The patient is the 6th child of 7 children. There is no valid
data about whether the pregnancy was planned or not.
History of birth
There is no valid data about the process of the patients
birth.

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)
when the patient first laugh or squirm when asked to play,
nor playing claps with others (6-9 months)

INTERMEDIATE CHILDHOOD PHASE (3-11 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 (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
junior high school period

ADULTHOOD
Educational History

Hes graduated from

junior high school.
Occupational history

He worked as a farmer.
He had a good
relationship with his
fellows. But now he
wont go to work.
Marital Status

Married

Criminal History
No criminal history
Social Activity
He is an outgoing person and
he has some close friends
Current Situation
He lives with his wife and
children

Eriksons stages of psychosocial development

Stage

Basic Conflict

Important Events

Trust vs mistrust

Feeding

Autonomy vs shame and

doubt

Toilet training

Preschool
(3-5 years)

Initiative vs guilt

Exploration

School age
(6-11 years)

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

Ego integrity vs despair

Reflection on life

Infancy
(birth to 18 months)
Early childhood
(2-3 years)

Adolescence
(12-18 years)

Maturity
(65- death)

History of Personal Life

Patient realizes that he is a male
Has interests to female
His attitude is appropriate as a male
SOCIO-ECONOMIC HISTORY
Economic scale

: low

VALIDITY
Alloanamnesis
Autoanamnesis

: valid
: not valid

Morning Report
Sunday, October 26th, 2014

EXAMINATION

Physical Examination
General physical examination

General appearance

Good nutritional status

Vital sign
BP
HR
to
RR

: 160/100 mmHg
: 100x/m
: afebris
: 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

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

Neurogical Examination
Cranial nerves examination:
The cranial nerves examination cant be assesed because the patient is
hyperactive and non cooperative
CN I
: cant be assesed
CN II
: cant be assesed
CN III,IV,VI : cant be assesed
CN V
: cant be assesed
CN VII
: cant be assesed
CN VIII
: cant be assesed
CN IX
: cant be assesed
CN X
: cant be assesed
CN XI
: cant be assesed
CN XII
: cant be assesed

Neurogical Examination
The neurogical examination cant be assesed because the
patient is hyperactive and non cooperative
Physiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+), brachioradial

(+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)

Pathological reflex
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski (-), chaddok (-),gordon (-),oppenheim (), rossolimo (-)
Motoric examination
Normal movement, good coordination, normal strength

Mental State Examination

Sunday, October 26th, 2014

Appearance:
a man, appropriate to his age, completely clothed

State of consciousness: foggy

Speech:
speak not spontaneously, intonation and speech

volume loud, unclear articulation, speech

productivity is poor

Mental State Examination

Behavior

Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Streotypy
Mannerism
Automatism
Bizzare
Command automatism

Mutism
Acathysia
Tic
Somnabulism
Psychomotor agitation
Compulsive
Ataxia
Mimicry
Aggresive
Impulsive
Abulia

Mental State Examination

Attitude:
Non-cooperative
Indiferrent
Apathy
Tension

Dependent
Passive
Infantile

Labile
Rigid
Passive negativism
Catalepsy

Cerea flexibility
Excited

Mental State Examination

Emotion:

Affect

Mood

Dysphoric
Euthymic
Elevated
Euphoria
Expansive
Irritable
Agitation
Cant be assesed

Appropriate
Inappropriate
Restrictive
Blunted
Flat
Labile

Mental State Examination

Disturbance of Perception

Hallucination

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

Illusion

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

Mental State Examination

Thought Progression

Quantity

Logorrhea
Blocking
Remming
Mutism
Talkative

Quality

Irrelevant answer
Coprolalia
Incoherence
Flight of idea
Poverty of speech
Confabulation
Loosening of association
Neologisme
Circumtansiality
Tangential
Verbigration
Perseveration
Sound association
Word salad
Echolalia

Cont
Content of Thought

Delusion of Grandiose

Idea of Reference

Idea of grandiose

Preoccupation

Obsession

Delusion of Influence

Phobia

Delusion of Passivity

Fantasy

Delusion of Perception

Delusion of Persecution

Delusion of Suspicion

Delusion of Reference

Thought of Echo

Delusion of Envious

Thought of Insertion & withdrawal

Delusion of Hypochondriac

Thought of Broadcasting

Delusion of Magic-mystic

Delusion of Control

Delusion of Religion

Cont
Form of Thought

Non Realistic
Dereistic
Autism

Cannot be evaluated

Sensorium and Cognition

Level of education

: finished junior high school

General knowledge
: unknown
Orientation of time
: bad
Orientations of place
: bad
Orientations of people
: bad
Orientations of situation
: bad
Working/short/long memory : unknown
Writing and reading skills
: unknown
Visuospatial
: unknown
Abstract thinking
: unknown
Ability to self care
: bad

Impulse control when examined

Self control: bad

Patient response to examiners question: bad

Insight
Impaired insight

Intellectual Insight
True Insight

Morning Report
Sunday, October 26th, 2014

RESUME

Resume
A male, 52 years old, appropriate according to her age
Symptom: Patient liked to talked by himself and locked up the room since 1

weeks ago.
Mental Status:
Behavior: Hyperactive
Attitude: Infantile and labile
Mood: Dysphoric, Labile
Progression of thought: Remming. Poverty of speech, irrelevant answer,
word of salad.
Hallucination: Visual
Impairment:
Patient is unable to perform daily activities well
He cant spend his free time well
Impairment of social function
Patient cant take care of himself well

Morning Report
Sunday, October 26th, 2014

DIAGNOSIS

Differential Diagnosis
F 05 Delirium due to Known Physiological Condition

F 06.1 Organic Catatonic

Multiaxial Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V

: F 05 Delirium due to Known Physiological

Condition
: Z03.2 No axis II diagnosis
: Hypertension
: None
: GAF admission 20-11

Morning Report
Sunday, October 26th, 2014

MANAGEMENT

Management Planning
Hospitalization
Patient tried to kill himself
Patient wont perform a job
Patient is unable to perform daily activities well
Impairment of social function
Patient cant take care of himself well
Emergency Department
Haloperidol 5mg im
Diazepam 5 mg iv
Wards
Haloperidol 5 mg po 2dd1
Finding about the underlying
causes

Response

Remission

Recovery

Response Phase
Target therapy :
50% decrease of symptoms

Maintenance
Haloperidol 5 mg po 2dd1

Re-assess patient

Remission Phase
Target therapy :
100% remission of symptom
Inpatient management
Haloperidol 5 mg 2 dd I
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!