Morning Report 17 Nov 2014 CBD 1

MORNING REPORT

Supervisor:Dr. Sabar P Siregar Sp.KJ

Morning ReportNovember 17, 2014Patients IdentityName: Mr. SMAge: 30 years oldGender: MaleAddress: KlatenOccupation: UnemployedMarriage Status : DivorcedLast Education : Senior High SchoolDate of Admission: November, 16th 2014

Guardians identityName: Mr. SAge: 61 years oldRelation: Father

Reason of admissionPatient brought to the hospital because he has been isolating himself from society and have sleep disturbance for 6 years.Stressor7 years ago (1 year before onset of symptoms which is 2008) he had a history of unrequited love. He once had a girl whom he liked but the woman ended up marrying another man when he worked abroad as a worker in South Korea.Progression of illnesPresent IllnessPsychiatric HistoryNo history of psychiatric disorderMedicationPatient hasnt been on drug/psychotropic.TraumaNo history of recent traumaDrugs and alcohol abuse history and smoking history- Alcohol consumption (+) in XI grade of SHS.- Tobacco consumption (+) 1 pack per day- Drug use (-) History of Personal LifePrenatal and Perinatal HistoryEarly childhood phaseIntermediate childhoodLate childhoodadulthoodPrenatal and Perinatal historyHis mother did not has any medical condition during pre and perinatal. The nutrition was well taken care.Her labor was aided by a midwife in a house. The mothers ageat the labor date was 22 yrs old.

Developmental History (Gross Motoric)AbilityResultNormal rangeElevating the headNormal0-3 monthsMoving to supine position on its ownNormal3-6 monthsSittingNormal6-9 monthsStandingNormal9-12 monthsWalkingNormal12-24 monthsClimbing up the ladderNormal24-36 bulanStanding 1 foot / jumpNormal 36-48 bulanEarly Childhood Phase (0-3 years old)1111 Developmental History (Fine Motoric)AbilityResultNormal rangeHolding a pencilNormal3-6 monthsHolding 2 objects at the same timeNormal6-9 months

Piling 2 cubesNormal9-12 monthsInserting objects into containerNormal12-18 monthsRolling a ballNormal18-24 monthsDoodlingNormal24-36 monthsWearing shirtNormal 36-48 months12 Developmental History (Language)AbilityResultNormal rangeOooh-aahNormal0-3 monthsTurning toward the soundNormal3-5 months

High-pitched soundNormal3-6 months

Voice without meaning (mamama, Bababa)Normal6-9 months

Calling 2-3 syllables without meaningNormal9-12 months

Calling 3-6 words that have meaningNormal18-24 months

Talking at least with two wordsNormal24-36 months

Mentioning name, age, and placeNormal 36-48 months

Oooh-aaahCalling 2-3 syllables without meaningCalling 3-6 words that have meaningThe name, age, place of13 Developmental History (Social & Personal)AbilityResultNormal rangeKnow their motherNormal0-3 monthsReach outNormal3-6 monthsClapNormal6-9 monthsPlaying peek a booNormal6-9 monthsKnow their familyNormal9-12 monthsAppoint what he wants without crying or whiningNormal12-18 monthsTidy up toysNormal24-36 monthsPlaying with friends, follow the rules of the gameNormal 36-48 months14

Intermediate Childhood (3-11 years old)PsychomotorNo valid data on when patient first time climbing the tree or play hide and seek games, and if patient ever involved in any kind of sports.Psychosocial There were no valid data on patients gender identification, interaction with his surroundingThere were no data on when patient first entered primary school, how well patient handle separation from parents, how well he plays with new friends on his first day of schoolCommunication There were no valid data regarding patients ability to make friends in school, and how many friends patient have during his schooling period.Emotion No valid data on patient adaptation under stressCognitive Patient went to preelemenary school at 5 years old. Then went to elementary school at 6 years old, but he was stay in 1th grade for 2 years.

Late Childhood and Teenage PhaseSexual Development Sign and Activity No data on when patient experience wet dream, growth hair on armpits, growth pubic hair, etc.Psychomotor NormalPsychosocial Patient had a girl in grade XIICommunication NormalEmotion Normal

Patient even got caught by the police because of alcohol use when he was at grade XII , the patient say that that is the first ecperience. Then he was moved from STM to SMA Muhamadiyah.

AdulthoodEducational HistorySenior High SchoolMarriage StatusDivorcedSocial ActivityNormal, usually hang out with friendsOccupational HistoryLabor at pressing manufacture in South Korea for 3 yers

Current SituationHe live with his father, mother, and his brother in-law.Religious HistoryMoslem, observantCriminal HistoryCaught by the police at because alcohol use.HistoryGenogramPatient

Housemate

Socioeconomic HistoryLow socioeconomic status. His father is a farmer.ValidityAlloanamnesis: ValidAutoanamnesis: ValidProgression of IllnessSymptomRole of Function200820142013Mental StatusAppearanceA male, appropriate to his age, wear complete clothes, good self grooming.State of ConsciousnessClearSpeech- Quantity: Decrease- Quality: Decrease(November 16, 2014) BEHAVIOURHypoactiveHyperactiveEchopraxiaCatatoniaActive negativismCataplexyStereotypy

MannerismAutomatismBizarreCommand automatismAcathysiaTicSomnabulismPsychomotor agitationCompulsiveAtaxiaMimicryAggresiveImpulsiveAbulia ATTITUDENon-cooperativeIndiferrentApathyTensionDependentInfantileDistrustLabileRigidPassive negativismCatalepsyCerea flexibilityExcitementMoodDysphoricElevatedEuphoriaExpansiveIrritableCant be assesedAffectAppropriateInappropriateRestrictedBluntedFlatLabileEMOTIONHallucinationAuditory (+) Visual (-) Olfactory (-) Gustatory (-)Tactile (-) Somatic (-)Undiferrentiated (-)

IllusionAuditory (-)Visual (-)Olfactory (-)Gustatory (-)Tactile (-)Somatic (-)Undiferrentiated (-)Depersonalization (-)Derealisation (-)Disturbance of PerceptionThought ProgressionQuantityLogorrheaBlockingRemmingMutismeTalkativeLack of ideas

QualityIrrelevant answerIncoherenceFlight of ideaConfabulationPoverty of speechSlow speechLoosening of association

NeologismeCircumtansialityTangential Verbigrasi Perseverasi Sound associationWord saladEcholaliaContent of thoughtIdea of ReferencePreocupationObsessionPhobia Delusion of PersecutionDelusion of ReferenceDelusion of EnviousDelusion of HipokondryDelusion of magic-mysticFantasy

Delusion of GrandioseDelusion of ControlDelusion of InfluenceDelusion of PassivityDelusion of PerceptionThought of EchoThought InsertionThought of withdrawalThought BroadcastingCant be assesed

11/19/201430Form of ThoughtRealisticNon RealisticDereisticAutistic

Sensorium and CognitionLevel of education: goodGeneral knowledge: poorOrientation of time/place/people/situation: goodWorking/short/long memory: poorWriting and reading skills: goodVisuospatial: goodAbstract thinking: poorAbility to self care: poor

Impulse Control When ExaminedSelf control :goodPatient response to examiners question:goodInsight Impaired insightIntellectual InsightTrue InsightInternal StatusConsciousness : Clear

Vital sign:- Blood pressure: 120/80 mmHg- Pulse rate : 80 x/mnt- Temperature : afebris- RR: 20 x/mntPhysical ExamHead-neck: CA (-), SI (-), lnn ttb

Thorax : Lung : Vesicular (+/+) Cor : S1-2 normal, regular

Abdominal : Peristaltic normal, no tendernessExtremities: NormalNeurological StatusMotoric : Normotonus, good coordination of movement Meningeal sign : negativePhysiologic reflex : +/+Pathologic reflex : -/-

Mental StatusMood: dysphoricAffect: restrictedDisturbance of perception: hallucination of: auditory(+), visual(-), olfactory(-), tactile (-)Thought progression:Quantity: remmingQuality: poverty of speechContent of thought : Ideas of refference(-), delusion of persecution(-)Form of thought: realisticImpairmentCant work anymore;Limited social interactionSymptoms

Isolating himself from societuyFoul language to his motherSleep disturbanceSmiling without any reasonPoor self grooming

Onset: 6 years agoStressor: unrequited loveSignificant Finding ResultYang normal tdk perlu ditulisSymptoms -> gejala yang dirasakan aja (bahasa awam)37Differential DiagnosesF32.3Severe Depression Episode with Psychotic SymptomF25.1 Depression-Type Schizoaffective Disorder Multiaxial DiagnoseAxis I: F32.3Severe Depression Episode with Psychotic SymptomAxis II: R46.8Axis III : No diagnosisAxis IV : Unrequited love Axis V: GAF admission 40-31

PROBLEM RELATED TO THE PATIENTProblem about patients lifeUnmarried despite his old ageUnemployedpoverty

Planning ManagementEMERGENCY ROOMInj Haloperidol IM 5mginj Diazepam IV 5 mg

Common reasons for hospital admissionSerious risk of suicideSerious risk of harm to others Significant self-neglect (esp. weight loss)Severe depressive symptomsSevere psychotic symptomsLack or breakdown of social supportsInitiation of ECTTreatment-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)

ECTFor depression with psychotic features, ECT should be considered as first-line therapy, as evidence supports the superior efficacy of ECT to pharmacotherapy in this patient group, with significant benefit in 80 - 90% of cases (N.B. Current NICE guidelines do not support this practice). However, often issues of consent or relative contraindications may preclude the immediate use of ECT and its role is often that of a second-line treatment after partial response or failure of pharmacotherapy.

Combination treatmentIt is usual to commence treatment with an antipsychotic agent (as for an acute psychotic episode) for a few days before commencing an antidepressant. This allows for a period of assessment (to exclude a primary psychotic disorder), may improve compliance (when psychotic symptoms are seen to improve with medication), avoids potential worsening of psychotic symptoms with an antidepressant (in some predisposed individuals), and may help identify the 30-50% of patients who do respond to an antipsychotic alone. There is no clear evidence for any particular combination of medication being more efficacious, but this approach is effective in 70-80% of patients

(Oxford Handbook of Psychiatry)

Maintenance therapyWhen ECT has been used, maintenance usually involves the treatment of the underlying depressive symptoms with an antidepressant (as in episodes without psychotic symptoms.

When combination treatment has been successful, maintenance often involves a clinically effective antidepressant with the lowest effective antipsychotic dose. As for dual-action agents, evidence is lacking with regards to long-term treatment and this tends to be pragmatic, on the basis of continued symptomatology.In view of the severity of the disorder, prophylactic use of an antidepressant and/or antipsychotic is prudent (often indefinitely, as for recurrent depressive episodes).

Thank YouEriksons Stages of Psychosocial DevelopmentStageBasic ConflictImportant EventsInfancy(birth to 18 months)Trust vs mistrustFeeding Early childhood(2-3 years)Autonomy vs shame and doubtToilet trainingPreschool(3-5 years)Initiative vs guiltExplorationSchool age(6-11 years)Industry vs inferioritySchoolAdolescence(12-18 years)Identity vs role confusionSocial relationshipsYoung Adulthood(19-40 years)Intimacy vs isolationRelationshipMiddle adulthood(40-65 years)Generativity vs stagnationWork and parenthoodMaturity(65- death)Ego integrity vs despairReflection on lifeConclusion: no clear data