Morning Report

FRIDAY MAY 8TH 2015

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

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mr. S
: 30 years old
: male
: Batang
: Unemployed
: Single
: Javanese
: Elementary

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

Name
Age
Sex
Address
Job
Marital status
Ethnicity
Educational status

: Mr. A
: 34 years old
: male
: Batang
: Employee
: Married
: Javanese
: S1

Reason brought to
hospital

Patient was brought by his brother

because he hit his mother by using a
stick and get easily angry

Progression of Illnes

2014

Patient start to get angry easily and irritable

Patient start to hear voices in his ear and see a ghost

Patient often wander

Patient still able to do ADL

Patient was hospitalized in RSJ Semarang

Progression of Disease

2015

Patient get angry easily, rage often, wander and talk to himself

Patient still can do ADL

4 days ago

Patient feels hard to sleep

Often daydreaming

Easily offended

Easily angry

Talk to himself

Seeing ghost

1 day ago

Patient hit his mother

Day of Admission

Patient was brought by his brother because his brother afraid the
patient can put others in danger

Patient will eat and take a bath only if told to do so

History of Past Illness

Psychiatric Illness

Hospitalized 1 year ago with the same symptom (11 days, patient
get better, didnt control to hospital)

General Illness

Patient has a few episodes of convulsion during infancy (his parent

didnt check to a doctor)

Patient has a retarded mental, known since elementary

Substance Abuse

Patient dont smoke, use drugs or drinks alcohol

Family History

There is no similar illness in the family

Physical Examination

Consciousness :CM, E4M5V6

Vital Sign

BP : 120/90 mmHg

HR : 90/min

RR : 24/min

General physical examination

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 (-), tremor +

 Cranial

nerves examination:

CN I

: not assessed

CN II

: not assessed

CN III,IV,VI : not assessed

CN V

CN VII

: not assessed

CN VIII

: not assessed

CN IX

: not assessed

CN X

: not assessed

CN XI

: not assessed

CN XII

: not assessed

: not assessed

Physiological reflex

Upper extremities: not assessed

Lower extremities: not assessed

Pathological reflex

Upper extremities: not assessed

Lower extremities: not assessed

Meningeal sign

not assessed

Cerebellum function

not assessed

Mental State
Examination

General appearance

A male, age 30 years old, appropriate to her age, and wearing good cloth, self
grooming enough

Consciousness

Clear

Orientation

Time

: good

People

: good

Place

: good

Situation : good

Behavior
Hypoactive
Hyperactive
Echopraxia
Catatonia
Negativism
Cataplexy
Stereotipy
Mannerism
Automatism
Command
automatism
Bizarre

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

Tremor
Floxilation
Loss of energy
Dischynesia
Muscle rigidity
Bradychynesia
Khorea
Convulsion
Dystonia
Aminia

Attitude
Cooperative
Non-cooperative
Indiferrent
Apathy
Tension
Dependent
Passive
Active

Infantile
Distrust
Labil
Rigid
Passive negativism
Stereotipy
Catalepsy
Cerea flexibility
Excited

Mood
Mood:
Euthymic
Elevated
Dysphoric
Euphoria
Expansive
Irritable

Affect:
Inappropriate
Restrictive
Blunted
Flat
Labile

Thought of perception
Halusinasi
Auditory (+)
Olfactory (-)
Visual (+)
Gustatory (-)
Tactile (-)
Somatic (-)
Undeferrentiated
(-)
Depersonalisation (-)

Ilusi

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

Thought progression
Kuantitas

Logorrhea
Talk active
Blocking
Remming
Mutism

Kualitas

Irrelevant 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

Delusion of control

Delusion of influence

Obsession

Delusion of grandiosity

Phobia

Delusion of perception

Preoccupation

of being

guilty

Delusion

of persecution

Thought echo

Delusion

of reference

Thought insertion

Delusion

of jealousity

Thought withdrawal

Delusion

of hipochondry

Thought broadcasting

Delusion

of magic-mystic

Cant be assessed

Idea

of suicide

Form of thought
Realistic
Non realistic
Dereistic
Autistic

Sensorium and cognitive

Level of education
General knowledge
Orientation of T/P/P/S
Working/short/long memory
Writing and reading skills
Ability to self care

:
:
:
:
:
:

poor
poor
good/ good/ good/ good
impaired
poor
decrease

Patient has a mental retardation

Impulse Control When

Examined
Self control: Enough
Patient response to examiners question:
poor

Insight
Impaired insight
Intellectual insight
True insight

A female 36 years,
Symptom:

Mental Status :

Impairment:

Talking to himself
Irritable.
Hit his mother and easily get
angry
Wandering
Heard voices and see ghost
Feel like being controlled
when he hit his mother

Behavior :
Hyperactive, bizzare
Attitude : Cooperative,
excited
Mood: Euphoria
Affect: inappropriate
Perseption: Auditory
and visual
hallucination
Thought
progression:Blocking,
Flight of ideas,
incoherent
Content of thought:
delusion of control
Form of thought of :
Non realistic
Insight: impaired
insight

Patient
cannot work
Patient
cannot
socialize
Patient can
be a thread
to the other

Patient has a mental

retardation

Syndrome

Impairment of socialization
Delusion of control
Auditoric hallucination
Visual hallucination

Sleep disorder
Hyperactive
Euphoria

Schizophrenia
syndrome

Depressio
n
Syndrome
Mania
Syndrome

Diagnosis Banding
F20.3

Skizofrenia Tak Terinci

F25.0

Schizoaffective tipe Mania

Multiaxial Diagnosis
Axis
Axis
Axis
Axis
Axis

I
: R. 69 (diagnosis Axis 1 Tertunda)
II
: F.70 RM Ringan
III : IV : V : GAF 20 - 11

Management Planning

Hospitalization

Angry and rampage without any reason.

He can be a threat to the others

Emergency Department

Inj. Diazepam 10 mg IV

Evaluation for Mental Retardation

Remission phase

Target therapy :

100% remission of symptom

Inpatient management

Risperidone tab 2mg 2x1

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

Continuation of pharmacotherapy

Psychosocial therapy

Recovery Phase

Continue the medication, control to psychiatrist for at least 1

year after hospitalization

Rehabilitation :

Help patient to socialize well with other

Give social support

Find a hobby

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 in brain

Mental disorders can be controlled by medicines, so it is important to

take the medicines routinely

Treat patient like you treat any other people

Help patient if he should be helped

Dont push patient to understand the family, but his family that has
to understand him

Dont be too emotional to patient

Thank You