Morning Report

Tuesday, November the 25th 2014

Patient’s Identity
 Name : Mr. A
 Age : 14 years old
 Sex : Male
 Address : Kaliwedi Lor, Banyumas
 Job : Unemployeed
 Marital status : Unmarried
 Ethnicity : Javanese
 Educational status : Elementary School (not
finished 5th grade)
 Identity
Alloanamnesis was conducted to :
I

Name Mr. S
Age 48 years old
Sex Male
Address Kebumen
Relationship Father

Strength of relationship Strong

Psychiatric history
 Chief Complaint
The patient often became angry and did not
want to do any work at home
Stressor
Can’t be assesed
 Progression of illnes
• The patient was influenced by his friends that he
April 2014 fancied watching pornography on his mobile
phone and internet store and did this many times.
(7 months The patient was unwilling to do anything he was
before supposed to do, becaming easily offended, often
admission) getting angry, and wandering off looking for
entertainment with his male friends.

• The patient behavior became worse by days; he was

October often caught daydreaming while talking and laughing
2014 with himselves, becoming too excited towards female
friends passing by, and was not shy if forgetting wearing
(1 month any pant or underwear. Lately, he snuggled and intend
before on suck on his mother’s breasts and sniffing the area
between his mother’s thighs. If his wishes were not given
admission) he would soon get furious with everyone at home.
History of Present Illness
The patient was brought to the emergency department by his father and uncle. His father
told that his son often became angry whenever his desire and want that were too expensive
were not accomodated by his parents. He also did not want to do any job or work offered
and always went out every night.

The patient’s parents did not know where the patient went to but he always ran out of his
money and became offended and angry if asked what he spent his money for. This
phenomeon had occured for almost 7 months ago and became worse by days.

The patient did not go to school anymore since last year due to many complaints about his
behavior that came from school and his inability to focus and concentrate about his study.
The patient had history of remaining in the same class because he did not pass his exam.

The patient confessed that he liked to go play out with his friends doing smoking, drinking
alcohol at the dangdut concert in his village, and going to the internet store for watching
porn movies. The parents said that he liked to muse (daydream) while talking unclearly and
laughing at himself everyday at home. The patient’s father also said that the patient
sometimes touched certain body part of his mother that were inappropriate for him to do
(snuggling and sucking the mother’s breasts; sniffing the area between his mother’s thighs).
History of Past Illness
 Psychiatric illness
Unspecified Schizophrenia 2 years ago (from puskesmas;
past history: sometimes could see a tall dark terrifying
ghost but did not talk to him, just passing by)

 General medical illness

 There is no history of high fever, seizure, head trauma, or
any other serious illness which needs hospitalization

 Substance abuse
 Smoking 5 cigarettes / day
Depiction of Illness
Symptoms
2014

Role
Function
Family History
There is no history of psychiatric illness in
patient’s family.
History of Personal Life
Prenatal
History of pregnancy
The pregnancy was planned (there was no
history of birth control use)

History of birth
He was born in home with the help of dukun
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 patient’s 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
▫ Patient had some friends at his village.
Emotional (NO VALID DATA)
▫ No valid data on patient’s emotional.
Cognitive
▫ The patient always seemed easily distracted and had difficulty
in concentration at school; his mark was almost never
satisfying
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 patient’s 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 patient’s emotional.
Communication (NO VALID DATA)
▫ The patient had difficulty in befriending with the girls
because they were scared of him
Infants
and Toddlers Physical
Newborn: rough, random,
uncoordinated, reflexive movement
3 mo: head at 90 degree angle, uses
arms to prop; visually track through
midline
5 mo: purposeful grasp; roll over;
head lag disappears; reaches for
objects; transfer objects from hand
to hand; plays with feet; exercises
body by stretching, moving; touch
genitals, rock on stomach for
pleasure
7 mo: sits in “tripod”; push head and
torso up off the floor; support weight
on legs; “raking” with hands
9 mo: gets to and from sitting; crawls,
pulls to standing; stooping and
recovering; fingerthumb opposition;
eyehand coordination, but no hand
preference
12 mo: walking
15 mo: more complex motor skills
2 yrs: learns to climb up stairs first,
then down
Cognitive Social
Sensori-motor: physically explores Attachment: baby settles when
environment to learn about it; parent comforts; toddler seeks
repeats movements to master comfort from parent, safe-base
them, which also stimulates brain exploration
cell development 5 mo: responsive to social stimuli;
4-5 mo: coos, curious and facial expressions of emotion
interested in environment 9 mo: socially interactive; plays
6 mo: babbles and imitates sounds games (i.e., pattycake)
9 mo: discriminates between With caretakers
parents and others; trial and error 11 mo: stranger anxiety;
problem solving separation anxiety; solitary play
12 mo: beginning of symbolic 2 yr: imitation, parallel and
thinking; points to pictures in books symbolic, play
in response to verbal cue; object
permanence; some may use single
words; receptive language more
advanced than expressive
language
15 mo: learns through imitating
complex behaviors; knows objects
are used for specific purposes
2 yrs: 2 word phrases; uses more
complex toys and understands
sequence of putting toys, puzzles
together
Emotional
Birth-1 yr: learns fundamental trust
in self, caretakers, environment
1-3 yr: mastery of body and rudimentary mastery of
environment (can get other’s to take care of him)
12-18 mo: “terrible twos” may begin; willful,
stubborn, tantrums
18-36 mo: feel pride when they are “good” and
embarrassment when they are “bad”
18-36 mo: Can recognize distress
in others – beginning of empathy
18-36 mo: are emotionally attached to toys or objects
for security
Possible effects of maltreatment
Chronic malnutrition: growth retardation,brain
damage, possibly mental retardation
Head injury and shaking: skull fracture, mental
retardation, cerebral palsy,paralysis, coma, death,
blindness,deafness
Internal organ injuries
Chronic illness from medical neglect
Delays in gross and fine motor skills, poor muscle tone
Language and speech delays; may not use language to
communicate
Insecure or disorganized attachment:
overly clingy, lack of discrimination of
significant people, can’t use parent as
source of comfort
Passive, withdrawn, apathetic,
unresponsive to others
“Frozen watchfulness”, fearful, anxious, depressed
Feel they are “bad”
Immature play – cannot be involved in reciprocal,
interactive play
 Physical
Physically active
Rule of Three: 3 yrs,3 ft, 33 lbs.
Weight gain: 4-5 lbs per year
Growth: 3-4 inches per year
Physically active, can’t sit still for long
Clumsy throwing balls
Refines complex skills: hopping,
jumping, climbing, running, ride
“bigwheels” and tricycles
Improving fine motor skills and eye-
hand coordination: cut with scissors,
draw shapes
3– 3,5 yr: most toilet trained
Cognitive
Preschool
Ego-centric, illogical, magical thinking
Explosion of vocabulary;
learning syntax, grammar;
understood by 75% of people by age 3
Poor understanding of time,
value, sequence of events
Vivid imaginations; some
difficulty separating fantasy
from reality
Accurate memory, but more
suggestible than older children
Primitive drawing, can’t
represent themselves in drawing till age
4 “good and bad” behavior
Don’t realize others have
different perspective
Leave out important facts
May misinterpret visual cues of
emotions
Receptive language better
than expressive till age 4
Social
Play:
Cooperative,imaginative, may involve
fantasy and imaginary friends, takes
turns in games
Develops gross and fine motor skills;
social skills;
experiment with social roles;reduces
fears
Wants to please adults
Development of conscience:
Incorporates parental prohibitions; feels
guilty when disobedient; simplistic idea
of
Curious about his and other’s bodies,
may masturbate
No sense of privacy
Primitive, stereotypic
understanding of gender roles
Emotional
Self-esteem based on what others tell him or her
Increasing ability to control emotions; less
emotional outbursts
Increased frustration tolerance
Better delay gratification
Rudimentary sense of self
Understands concepts of right and wrong
Self-esteem reflects opinions of significant others
Curious
Self-directed in many activities
Possible effects of maltreatment
Poor muscle tone, motor coordination
Poor pronunciation, incomplete sentences
Cognitive delays; inability to concentrate
Cannot play cooperatively; 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
Excessively fearful, anxious, night terrors
Reminders of traumatic experience may trigger severe
anxiety, aggression, preoccupation
Lack impulse control, little ability to delay gratification
Exaggerated response (tantrums, aggression) to even mild
stressors
Poor self esteem, confidence; absence of initiative
Blame self for abuse, placement
Physical injuries; sickly, untreated illnesses
Eneuresis, encopresis, self stimulating behavior –rocking,
head-banging

Physical
Slow, steady growth: 3 -4 inches per
year
Use physical activities
to develop gross and fine motor skills
Motor & perceptual
motor skills better integrated
10-12 yr: puberty
begins for some children
School Aged
Cognitive
Use language as acommunication tool
Perspective taking:
5-8 yr: can recognize others’
perspectives, can’t assume the role of
the other
8–10 yr: recognize difference between
behavior and intent; age
10-11 yr: can accurately
recognize and consider
others’ viewpoints
Concrete operations:
Accurate perception of
events; rational, logical
thought; concrete thinking; reflect upon
self and attributes; understands
concepts of space, time, dimension
Can remember events
from months, or years
earlier
More effective coping skills
Understands how his
behavior affects others
Social
Friendships are situation
specific
Understands concepts
of right and wrong
Rules relied upon to
guide behavior and play, and provide
child with structure and security
5-6 yr: believe rules can
be changed
7-8 yrs: strict adherence
to rules
9-10 yrs: rules can be
negotiated
Begin understanding social roles;
regards them as inflexible; can adapt
behavior to fit different situations;
practices social roles
Takes on more responsibilities at home
Less fantasy play, more
team sports, board games
Morality: avoid punishment; self
interested exchanges
Emotional
Self esteem based on ability to perform and produce
Alternative strategies for dealing with frustrationand
expressing emotions
Sensitive to other’s opinions about themselves
6-9 yr: have questions about pregnancy, intercourse,
sexual wearing, look for nude pictures in books,
magazines
10-12 yr: games with peeing, sexual activity (e.g.,
strip poker, truth/dare, boy-girl relationships, flirting,
some
kissing, stroking/rubbing, reenacting intercourse with
clothes on)
Possible effects of maltreatment
Poor social/academic adjustment in school: preoccupied, easily
frustrated, emotional outbursts, difficulty concentrating, can be
overly reliant on teachers; academic challenges are threatening,
cause anxiety
Little impulse control, immediate gratification, inadequate coping
skills, anxiety, easily frustrated, may feel out of control
Extremes of emotions, emotional numbing; older children may
“self-medicate” to avoid negative emotions
Act out frustration, anger, anxiety with hitting, fighting, lying,
stealing, breaking objects, verbal outbursts, swearing
Extreme reaction to perceived danger (i.e.,“fight, flight, freeze”
response)
May be mistrustful of adults, or overly solicitous,manipulative
May speak in unrealistically glowing terms about his parents
Difficulties in peer relationships; feel inadequate around peers;
over-controlling
Unable to initiate, participate in, or complete activities, give up
quickly
Attachment problems: may not be able to trust, tests commitment
of foster and adoptive parent with negative behaviors
Role reversal to please parents, and take care of parent and
younger siblings
Emotional disturbances: depression, anxiety, post traumatic stress
disorder, attachment problems, conduct disorders
 Adolescents
Physical Cognitive
Growth spurt: Formal operations: precursors in early
Girls: 11-14 yrs adolescence, more developed in middle and
Boys: 13-17 yrs late adolescence, as follows:
Puberty: Think hypothetically: calculate consequences of
Girls: 11-14 yrs thoughts and actions without experiencing them;
Boys: 12-15 yrs consider a number of possibilities and plan
Youth acclimate to changes in body behavior accordingly
Think logically: identify and reject hypotheses
or possible outcomes based on logic
Think hypothetically, abstractly, logically
Think about thought: leads to introspection and
selfanalysis
Insight, perspective taking: understand and
consider others’ perspectives, and perspectives
of social systems
Systematic problem solving: can attack a
problem, consider multiple solutions, plan a
course of action
Cognitive development is uneven, and impacted
by emotionality
Social
Young (12 – 14):
Psychologically distance self from
parents;identify
with peer group; social status largely
related to group membership; social
acceptance depends on conformity to
observable traits or roles; need to be
independent from all adults; ambivalent
about
sexual relationships, sexual behavior is
exploratory
Middle (15 – 17):
friendships based
on loyalty, understanding, trust; self-
revelationis first step towards intimacy;
conscious choices about
adults to trust; respect honesty & straight
for wardness from adults; may become
sexually active
Morality: golden rule;
conformity with law is necessary for good
of society
 Emotional
Psycho-social task is identity formation
Young adolescents (12-14): selfconscious about
physical appearance and early or late development;
body image rarely objective, negatively affected by
physical and sexual abuse; emotionally labile; may
over-react to parental questions or criticisms; engage in
activities for intense
emotional experience; risky
behavior; blatant rejections of
parental standards; rely on peer
group for support
Middle adolescents (15-17):
examination of others’ values,
beliefs; forms identity by organizing perceptions of
ones attitudes, behaviors, values into coherent “whole”;
identity includes positive self image comprised of
cognitive and affective components
Additional struggles with identity
formation include minority or biracial status, being an
adopted
child, gay/lesbian identity
Possible effects of maltreatment
All of the problems listed in school age
section
Identity confusion: inability to trust in self to be a
healthy adult; expect to fail; may appear immobilized
and without
Direction
Poor self esteem: pervasive feelings of guilt, self-
criticism, overly rigid expectations for self, inadequacy
May overcompensate for negative selfesteem by being
narcissistic,
unrealistically self-complimentary;
grandiose expectations for self
May engage in self-defeating, testing, and aggressive,
antisocial, or impulsive
behavior; may withdraw
Lack capacity to manage intense
emotions; may be excessively labile, with frequent and
violent mood swings
May be unable to form or maintain
satisfactory relationships with peers
Emotional disturbances: depression,
anxiety, post traumatic stress disorder,
attachment problems, conduct disorders
ADULTHOOD
• Educational History
He was not graduated from  Criminal History
elementary school and No criminal history
remaining at the same
class because of failing his
exams twice  sent to
pondok pesantren  Social Activity
He only went out with several
certain male friends wandering off
the village looking for
• Occupational history entertainment.
No occupation history

 Current Situation
• Marital Status He lives with his father, mother, and
No marriage history his 2 younger siblings.
 Erikson’s
Stage stagesBasic
of psychosocial
Conflict Important Events
Infancy
(birth development
Trust vs mistrust Feeding
to 18 months)
Early childhood Autonomy vs shame
Toilet training
(2-3 years) and doubt
Preschool
Initiative vs guilt Exploration
(3-5 years)
School age
Industry vs inferiority School
(6-11 years)
Adolescence
Identity vs role confusion Social relationships
(12-18 years)
Young Adulthood
(19-40 years) Intimacy vs isolation Relationship

Middle adulthood Generativity vs Work and

(40-65 years) stagnation parenthood
Maturity
Ego integrity vs despair Reflection on life
(65- death)
History of Personal Life
• Patient acknowledged that he was a male
• Had interests to female
• His attitude was described by his father as
inappropriate towards his female friends

SOCIO-ECONOMIC HISTORY
• Economic scale: enough

VALIDITY
• Alloanamnesis : valid
• Autoanamnesis : valid
Genogram
Examination
Physical Examination
 General physical examination
 General appearance :
 Good nutritional status
 Vital sign :
 BP : 100/80 mmHg
 HR : 80 x/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
 Extremity : Warm acral, capp refill <2”, edema (-)
Neurogical Examination
 Cranial nerves examination:
 CN I : in normal finding
 CN II : 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
Neurogical Examination
 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
 Appearance:
a man, appropriate to his age, completely
clothed, tidy

 State of consciousness: clear

 Speech:
 speak
unspontaneously but unclearly (inability of
making proper words by himself), intonation and
speech volume appropriate, clear articulation
Mental State Examination
Behavior

• Hypoactive • Mutism
• Hyperactive • Acathysia
• Tic
• Echopraxia
• Somnabulism
• Catatonia • Psychomotor agitation
• Active negativism • Compulsive
• Cataplexy • Ataxia
• Streotypy • Mimicry
• Mannerism • Aggresive
• Impulsive
• Automatism
• Abulia
• Bizzare
• Command automatism
 Mental State Examination
Attitude:
• Non-cooperative
• Indiferrent
• Labile
• Apathy
• Rigid
• Tension
• Passive negativism
• Dependent
• Catalepsy
• Passive
• Cerea flexibility
• Infantile
• Excited
 Emotion:
Mental State Examination
Mood Affect
• Dysphoric • Appropriate
• Euthymic • Inappropriate
• Elevated • Restrictive
• Euphoria • Blunted
• Expansive • Flat
• Irritable • Labile
• Agitation
• Can’t be assesed
 Mental State Examination
 Disturbance of Perception
Hallucination Illusion

• Auditory (-) • Auditory (-)

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

Depersonalization (-) Derealization (-)

Mental State Examination
 Thought Progression
Quantity Quality
• Irrelevant answer
• Coprolalia
• Logorrhea • Incoherence
• Blocking • Flight of idea
• Remming • Poverty of speech
• Confabulation
• Mutism • Loosening of association
• Talkative • Neologisme
• Circumtansiality
• Tangential
• Verbigration
• Perseveration
• Sound association
• Word salad
• Echolalia
 Mental State Examination
 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 Magic-mystic
• 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
• Thought of Withdrawal
• Thought of Broadcasting
Mental State Examination
Form of Thought

 Realistic
 Non Realistic
 Dereistic
 Autistic
Sensorium and Cognition
 Level of education : not finished elementary
school
 General knowledge : not examined
 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 : not examined
 Abstract thinking : poor
 Ability to self care : good
Impulse control when
examined
 Self control: enough
 Patient response to examiners question: good
Insight
 Impaired insight
 Intellectual Insight
 True Insight
Resume
Significant Finding Resume
Onset: 7 months ago
Symptoms
• Daily musing and
daydreaming
• Inappropriate actions
towards his female friends
and mother
• Wandering off with his
friends irresponsibly
• Aggressive on demanding
something he wants
• Difficulty on concentration
and conveying appropriate
words
• Liked to watch porns
Mental status Impairment
• Mood: elevated
The patient was never
willing to do anything
• Affect: appropriate he was supposed to do
• Thought progression:
quality  flight of
idea; quantity:
talkative
• Form of thought:
Autistic
• Impaired insight
Diagnosis
Differential diagnosis
F65.2 Ekshibisionisme
F65.3 Voyeurisme
Multiaxial Diagnose
Axis I: F65.3 Voyeurisme
Axis II : F70 Retardasi Mental
Ringan
Axis III : None
Axis IV : None
Axis V : GAF 30-21
 PROBLEM RELATED TO THE
PATIENT
1. Problem about patient’s life (social)
Unwilling to do anything he was supposed to do; unending
demands of expensive things; offended and angry when the
demands were not given; inappropriate acts towards female
friends and mother; daily daydreaming; addiction on watching
pornography

2. Problem about patient’s biological state (biology)

Unknown; hypothesis: a certain disfunction on temporal lobe of cerebri

3. Problem about patient’s mental state (psychology)

Hyperactivity; elevated; excited; flight of idea; talkative; autistic;
impaired insight
PLANNING MANAGEMENT
PLANNING MANAGEMENT
INPATIENT (HOSPITALIZATION)
 Pharmaco therapy:
- Antidepressant  Reduce obsessive compulsive behavior
Fluoxetine 1x20 mg
- Progestagen  reducing sexual drive
Medroksiprogesteron Asetat 150 mg IV per 3 months

 Psychotherapy

Response Remission Recovery

PLANNING MANAGEMENT
Emergency department
Common reasons for hospital
admission
 Serious risk of suicide
 Serious risk of harm to others
 Significant self-neglect
 Severe depressive symptoms
 Severe psychotic symptoms
 Lack or breakdown of social supports
 Initiation of ECT
 Treatment-resistant depression (where inpatient monitoring
may be helpful)
 A need to address comorbid conditions (e.g. physical
problems, other psychiatric conditions, inpatient detoxification)

(Oxford Handbook of Psychiatry)

 RESPONSE PHASE
Target therapy :
50% decrease of symptoms

Maintenance
 REMISSION PHASE
 Target therapy :
- 100% remission of symptom

 Inpatient management
-
 Outpatient management
-
RECOVERY PHASE
Thank you