morport 05.08.14

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MORNING REPORT

Tuesday , August 5th 2014

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Patient Identity

Autoanamnesis Name : Mr. R Sex : Male Age : 16 years old Address : Tegal Occupation : Elementary School Marital State : Single

Alloanamnesis Name : Ms. I

Sex : Female Relation : Patient’s mother

Age : 55 years old

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CHIEF COMPLAIN : PATIENT DIDN’T WANT TO EAT FOR 7 DAYS

Reason patient was brought

to emergency room

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Stressor

His mother and his aunt often toargue and fight

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Present History

Patient didn’t want to eat since 7 days ago

Patient has difficulty in sleeping since 15 days ago

Patient didn’t want to go to school since 15 days ago

Patient often talked to himself

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Day of Admission August 5th 2014

Patient was brought withthe reasons of:

• Patient didn’t want to eatsince 7 days ago

• Patient has difficulty insleeping since 15 days ago

• Patient often talked tohimself

Brought to hospital by his mother

Social Activity ImpairmentSelf Care Impairment

Patient didn’t want to go to school

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Psychiatric History

2 years ago, patient washospitalized and diagnosed with

skizofrenia at RSUD Kardinah,Tegal for 7 days. 1 year ago, patient was recurrent, he was sent to RSUD

Kardinah, Tegal. Patient had themedicine therapy for 2 weeks after

he went out from hospital.

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• Head injury (-)

• Hypertension (-)

• Convulsion (-)

• Asthma (-)

• Allergy (-)

Generalmedical

history

•Drugs consumption (-)

•Alcohol consumption (-)

•Cigarette Smoking (-)

Drugs and

alcohol abusehistory and

smoking history

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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric 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 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)

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Communication

Started saying words like “mom” or “dad”. (1 years old)

Emotion

His mother forgot on patient’s reaction when playing,frightened by strangers, when starting to show jealousy orcompetitiveness towards other and toilet training.

Cognitive

His mother forgot on which age the patient can follow objects,recognizing her mother, recognize her family members.

His mother forgot on when the patient first copied sounds that were heard, or understanding simple orders.

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INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor Forgot on when patient’s first time playing hide and seek or if patient

ever involved in any kind of sports.

Psychosocial

Late development regarding patient psychosocial. Communication Forgot regarding patient ability to make friends at school and how

many friends patient have during his school period

Emotional Forgot on patient’s emotional.

Cognitive Forgot on patient’s cognitive.

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LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA) No data on when patient first experience of nocturnal emission , 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 regarding patient psychosocial.

Emotional (NO VALID DATA) No valid data on patient’s emotional.

Communication (NO VALID DATA) No valid data regarding patient ability to make friends at school and

how many friends patient have during his high school period

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Erikson’s stagesof psychosocial development

Stage Basic Conflict Important Events

Infancy(birth to 18 months)

Trust vs mistrust Feeding

Early childhood(2-3 years)

Autonomy vs shame anddoubt

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

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FAMILY HISTORY

Patient is the only child of his parents.

There were no psychiatric history in his family.

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Male

Female Has psycic disorder Lives together

GENOGRAM

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PSYCHOSEXUAL HISTORY

Patient realizes that he is a male andinterested in woman. His attitude is

appropriate as a male.

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Socio-economic history

• Economic scale : moderate

Validity

• Alloanamnesis : valid• Autoanamnesis : valid

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Mental State - August 5th 2014

Appearance

• A male, appropriate to his age, completely clothed,poor grooming

State of Consciousness

• clear

Speech• Quantity : remming

• Quality : inkoheren

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BEHAVIOUR

•Hypoactive

•Hyperactive

•Echopraxia

•

Catatonia•Active negativism

•Cataplexy

•Stereotypy

•Mannerism

•Automatism•Bizarre

•Command automatism

•Acathysia

•Tic

•Somnabulism

•Psychomotor agitation

•Compulsive

•Ataxia

•Mimicry

•Aggresive•Impulsive

•Abulia

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ATTITUDE

• Non-cooperative

• Indiferrent

• Apathy

• Tension• Dependent

• Passive

•

Cooperative

•Infantile

•Distrust

•Labil

•Rigid

•Passive negativism

•Catalepsy

•Cerea flexibility

•

Excited

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Emotion

Mood

• Dysphoric• Euthymic

• Elevated

• Euphoria

• Expansive

• Irritable

• Agitation

Affect

• Inappropriate• Restrictive

• Blunted

• Flat

• Labile

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Disturbance of Perception

Hallucination

• Auditory (+)• Visual (-)• Olfactory (-)• Gustatory (-)

• Tactile (-)• Somatic (-)

Illusion

• Auditory (-)• Visual (-)• Olfactory (-)• Gustatory (-)

• Tactile (-)• Somatic (-)

Depersonalization (-) Derealization (-)

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Thought Progression

Quantity

• Logorrhea• Blocking

• Remming• Mutism

• Talk active

Quality

• Irrelevant answer

• Incoherence• Flight of idea

• Poverty of speech

• Confabulation

• Loosening of association

• Neologisme

• Circumtansiality• Tangential

• Verbigration

• Perseveration

• Sound association

• Word salad

• Echolalia

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Content of Thought

•

Idea of Reference• Idea of Guilt

• Preoccupation

•

Obsession• Phobia

• Delusion of Persecution

• Delusion of Reference

• Delusion of Envious

• Delusion of Hipochondry

• Delusion of magic-mystic

•

Delusion of grandiose• Delusion of Control

• Delusion of Influence

• Delusion of Passivity

• Delusion of Perception

• Delusion of Suspicious

• Thought of Echo

•

Thought of insertion• Thought of withdrawal

• Thought of Broadcasting

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Form of Thought

•Non Realistic

•

Dereistic•Autism

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Sensorium and Cognition

Level of education : finished elementaryschool

General knowledge :High 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 : Good Abstract thinking : Good Ability to self care : Good

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Impulse control whenexamined

• Self control: poor

• Patient response toexaminers question:

poor

Insight

• Impaired insight

• Intellectual Insight

• True Insight

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Physical State

Consciousnes : cloudy

Vital sign :

◦ Blood pressure : 120/70 mmHg

◦ Pulse rate : 84 x/mnt

◦ Temperature : 36,5 C

◦ RR : 22 x/mnt

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Review System

Head : normocephali, mouth deviation (-)

Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax :Cor : S 1,2 regular

Lung : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill <2”, motoric strength Neurological exam : not examined

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MentalStatus

Impairment

• Behavior: echopraxia,stereotypy, bizarre

-Attitude: cooperative,passive negativism

-Affect: blunted-Thought of Progression:remming, poverty of

speech

-Hallucination: auditorik

• Patient didn’t want to eat•Patient often

talked to himself,couldn’t sleep since

7 days ago.

- Self careimpairment

- Social activity

impairment

Symptoms

Patient is a male, 16 years old, self care and social activity impairment, didn’t want togo to eat

RESUME - Day of admission

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Axis I : F 20.4 Depresi Pasca-skizofrenia

Axis II : Z 03.2 no diagnosis

Axis III : no diagnosisAxis IV : masalah dengan “primary support

group” (keluarga)

masalah berkaitan dengan

lingkungan sosialAxis V : GAF scale 40-31

Multiaxial Diagnosis

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Differential Diagnosis

F 25.1 Skizoafektif Tipe Depresif

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PROBLEM RELATED TO THE PATIENT

Problem about patient’s lifeoHis mother and his aunt often to argue and fight

o

He doesn’t have any friends

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PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION)

•

Patient didn’t want to eat for 7 days • Patient had difficulty in sleeping for 15 days

• Hallucination auditorik

Response Remission Recovery

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RESPONSE PHASE

Target therapy :

50% decrease of symptoms

Emergency department

MedicationInj Diazepam 1 amp IV

Inj Lodomer 1 amp IM

Re-assess patient

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REMISSION PHASE

Target therapy : 100% remission of symptom

Inpatient management Continue the pharmacotherapy: Risperidon tab 2x3 mg 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 sparetime, and find a job that fits her well.)

Outpatient management Pharmacotherapy Psychosocial therapy

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RECOVERY PHASE

Continue the medication, control to psychiatric

Rehabilitation :- Family education

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Thank you

morport 05.08.14

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