Morning report

monday , April 15 nd 2013

Supervisor : dr Sabar P Siregar Sp.KJ

dr Riati

IDENTITY • Name : Mr M• Age : 22 years old• Status : Single• Occupation : Parking Attendant• Address : Purworejo• Education : Senior high school

• Alloanamnesis• Name : Mr R• Age : 55 years old’• Relation : Father

II.Chief complaint

Got Rage

1 months ago

Patient got rage and broke every stuff around him. He hits his father because his father doesn’t want to

give money for going to Kalimantan. After that incidence, the patient got irritable, laughing and

talking by himself.He also feels happy, he denied heard any voices or see any others can’t see,

suicide idea.

History of illness

PAST ILLNESS HISTORY

Psychiatry history

• First psychiatry disorder about ± 6 years ago.

• Patients had a history of outpatient treatment and taking medication adequate.

General medical history

• Pre-Hypertension (-)

• Head injury (-) • Asthma (-)• Febrile seizure

(-)

Drugs and alcohol abuse history and smoking history

• Alcohol consumption(-)

• Tobacco consumption (+)

• Drug use (-)

PRENATAL AND PERINATAL

• There is no data about his mother condition when she is pregnant.

• Patient delivered through normal delivery, at term

Early Childhood Phase (0-3 Years Old) (Continue)

• Psychomotoric (NO VALID DATA)– Normal growth and development in terms of head, rolling over, sitting,

crawling, standing, holding objects in his hand, putting everything in his mouth, holding objects in his hand, begin walking is unknow.

• Psychosocial (NO VALID DATA)• There were no data of patient when started smiling,startled by noises, first

laughed.– Communication (NO VALID DATA)

– Patient’s first words begin is unknow.

• Emotion (NO VALID DATA)– There were no valid data how patient showed normal reaction when

playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

• Cognitive (NO VALID DATA)– There were no valid data on which age the patient can follow objects,

recognizing her mother, recognize her family members.– There were no valid data on when the patient first copied sounds that

were heard, or understanding simple orders.

Intermediate Childhood (3-11 y.o)• Psychomotor

– No valid data on when patient’s first time riding a tricycle or bicycle, if patient ever involved in any kind of sports.

• Psychosocial– There were no data on patient’s gender identification.

• Communication– There were no valid data on socialization.

• Emotional– No valid data on patient’s adaptation under stress

• Cognitive– There were no valid data in terms of grades in school

Late Childhood & Teenage Phase Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpits and pubis, etc Psychomotor

There were no valid data of favourite hobbies or games Psychosocial

Having a lot of friends. Patient claimed to have relationship with opposite gender.

Emotional Patient expressed to mother regarding any problems.

Communication No valid data.

Adulthood

Educational and Occupational History : patient’s last education is senior high school

Marital status : single Legal History : Never been arrested or caught by

police. Social Activity : social withdrawal Current Situation : Living with his family Religious History : Fair

Family History

There is no any family member like him.

Psychosexual history

• Patient psychosexual history is appropriate of his gender and attracted to woman.

Genogram

:Female

:Male

: Patient

•Economic scale: low Socio-economic history

•Alloanamnesis : valid•Autoanamnesis : validValidity

Progression of Ilnesssymptom

Role function

2007 2009 2013

III Mental State Appearance :

Adult man, appropriate according to age, well dressed

State of Consciousness

Clear

Speech:

◦ Quantity : Normal

Quality : normal

Behaviour

HypoactiveNormoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStreotypyMannerismAutomatism

Command automatismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia

ATTITUDECooperativeIndiferrentApathyTensionDependentActivePassive

InfantileDistrustLabileRigidPassive negativismStereotypyCatalepsyCerea flexibility

Emotion

Mood

• Dysphoric• Euphoria• Elevated• Expansive• Irritable

Affect

• Appropriate• Inappropriate• Restrictive• Blunted• Flat• Labile

Disturbance of perception

Hallucination•Auditory•Visual •Olfactory •Gustatory •Tactile •Somatic

Illusion•Auditory •Visual •Olfactory •Gustatory •Tactile •Somatic

Thinkingthought progression

Quantity• Logorrhea• Blocking• Remming• Mutisme• Talk active

Quality•Irrelevan answer•Incoherence•Flight of idea•Confabulation•Poverty of speech•Loosening of association•Neologisme•Circumtansiality•Tangential •Verbigrasi •Perseverasi •Sound association•Word salad•Echolalia•coherence

Thought Processcontent of thought

Idea of reference

Preokupasi

Obsesi

Fobia

Delution of persecution

Delution of Grandiosity

Delution of envious

Delution of hipokondri

Delusion of nihilistik

Delusion of control

Delusion of influence

Delusion of passivity

Delusion of perception

Thought of echo

Thought of insertion/withdrawal

Thought of broadcasting

Thought form

• Form of Thought

RealisticNon RealisticDereisticAutistic

SENSORIUM and cognition

Level of education : low General knowledge: easy to be assessed Orientation of time : good place : good people : goodworking/short/long memory: good Writing and reading skills: good Visuospatial : good Abstract thinking : good Ability to self care : enough

• Self control : enough• Patient response to

examiners question: good

Impulse control when

examined

• Impaired insight• Intelectual Insight• True Insight

Insight

IV. PHYSICAL EXAMINATION

Internal Status• Conciousness : compos mentis• Vital sign:

– Blood pressure : 120/70 mmHg– Pulse rate : 84x/mnt– Temperature : afebris– RR: : 24x/mnt

Head : normocephali

Eyes : anemic conjungtiva -/-, icterik sclera -/-,

pupil isocore

Neck : normal, no rigidity, no palpable lymphnode

Thorax:

Chor : S1 and S2 Sound and normal

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

Abdomen : Pain - , peristaltic normal, thympany sound

Extremity : Warm acral, capp refill <2”

Neurological status

• Motoric : not tested• Physiological reflex : not tested• Pathological reflex : not tested

SIGNIFICANT FINDING RESUME

Onset•± 6 years ago patient :•Social withdrawal•± 1 months ago patient:•Irritable•Laughing and Talking by himself without anyone around

Mental Status

•Cooperative•Appropriate•Elevated mood•Impaired insight.

Impairment

•Role function: ability to work•Spare time: hangout with his friends•Psycho-social : poor with his family•Ability to self care : enough

Differential Diagnose

• F60.3 Unstable emotional disorder • F20.5 Residual Schizophrenia

• VII. DIAGNOSTIC FORMULATION

Multiaxial Diagnose

Axis I : Unstable Emotional Disorder. Axis II : no diagnosis Axis III : no-diagnosisAxis IV : Family Axis V : GAF 60-51

Planning therapy

• Medication-Initial Therapy: Diazepam 1 amp IV, Haloperidol IV.-Risperidon 2 x 2mg

Therapy

• Family education• Explain to his family about this patient mental

disorder• Describes steps of treatment• Family must maintain the patient’s drugs

consumption and routine doctor consultation, so it will increase the efficacy of treatment

• Family must keep in touch with patient intensively.

PROGNOSIS• Ad vitam : dubia ad malam• Ad functionum : dubia ad malam• Ad sanationum : dubia ad malam