Morning Report - 18-11-13 - Ana-lisa

8/13/2019 Morning Report - 18-11-13 - Ana-lisa

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MONDAY, NOVEMBER 18th2013

Supervisor:

dr. Sabar P Siregar, Sp. KJ


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Patient

Name : Mr. P

Age : 32 years old

Gender : Male

Address : Krajan RT 06RW 02 Tempuran,Wonosobo

Occupation : Basket weaver

Marriage Status : Married

Religion : Moeslem

Last Education: Elementaryschool

Guardian

Name : Mr. SM

Age : 23 years old

Relation : younger brother


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Causes brought patient to the hospital

Patient often angry without any reason


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Stressor

Family problem(there is a man that

like his wife)


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Irritable patient

Hit without any reason

Impulsive

Damage householdappliances

Solitaire

Talk alone and laughalone

Often hear the sound ofa whisper

Often complained ofchest abd stomachfeels hot

Lazy to work

Cant communicate

Lost of appetite

Lazy to take a bath

5days

ago

Dont want to

work anymore;

Social

withdrawal;

impairment

spare time;

Bad self

grooming


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Patient feel no energy

Silent as a statue, butsuddenly hit the

cupboard

3 daysago


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Often angry without any reason

Silent as a statue, suddenly hitthe cupboard

Solitaire

Often hear the sound of awhisper

Often complained of chest abd

stomach feels hotPatient fell no energy

Often sleep

Lazy to work

Lazy to take a bath

Lost of appetite

The day

patientbroughtto

hospital

Dont want to

work anymore;

Socialwithdrawal;

impairment

spare time;

Bad self

grooming


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PsychiatryHistory

-Had beentreated 3 times(2010 & 2011)

GeneralMedical History

Fever (-) Convulsion (+)

Asthma (-)

Allergy (-)

Head injury (+)

Drugs andalcohol abuse

history andsmoking history

Alcoholconsumption (-)

Tobaccoconsumption (+)

drug use (-)


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PRENATAL AND PERINATAL HISTORY (NO VALID DATA)

No data medical conditions & nutritions during the

mothers pregnancy.

Patient was born by normal delivery birth was helped by

midwife No data where patient was born.


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Psychomotoric (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 object in his hand (3-6 months)

Putting everything in his head (3-6 months)


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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 patient first laugh or squirm when asked to play or

playing claps with others (6-9 months) Communication (NO VALID DATA)

There were no valid data on when patient start saying words likema or pa (6-9 months)

Emotion (NO VALID DATA)

There were no valid data of patients reaction when playing,frightened by strangers, when starting to show jealousy orcompetitiveness towards other and toilet training.

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

recognize his mother, recognize his family member

There were no valid data on when patient first copied sounds thatwere heard, or understanding simple orders.


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Psychomotor (NO VALID DATA)

No valid data on when patient first time climbing the tree or playhide and seek games, and if patient ever involved in any kind ofsports.

Psychosocial (NO VALID DATA)

There were no valid data on patients gender identification, interactionwith his surrounding

There were no data on when patient first entered primary school, howwell patient handle separation from parents, how well he plays with newfriendson first day of school

Communication (NO VALID DATA)

There were no valid data regarding patients ability to makefriends in school, and how many friends patient have during hisschooling period.

Emotion (NO VALID DATA)

No valid data on patient adaptation under stress

Cognitive (NO VALID DATA)

No valid data on patients grades in school


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Sexual Development Sign and Activity (NO VALID DATA)

No data on when patient experience wet dream, growth hair onarmpits, growth pubic hair, 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 on when and how patients relationship with differentgender, if patient ever had any relationship with opposite gender.

Communication (NO VALID DATA)

No valid data on how well the relathionship between patient withparents and other family.

Emotion (NO VALID DATA) No data if patient ever told friend or family regarding any problems

No data if patient attempted to break the rules (truant schoolsubject, fight with friends, bullying, ect) and consuming alcohol,smoke and drugs


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Educational History

Elementary school

Marriage Status

Married, with his ownchoice, love his child, butsometimes temperament

with his wife

Social Activity

He has a lot offriends

Occupational History

Had been work at garageshop on 2005, now he work

as a basket weaver

Current Situation

Live with his parents,brother and two

children

Religious History

Always pray inmosque, after illness,

patient always

wudhu

Criminal History

None


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Stage Basic Conflict Important Events

Infancy

(birth to 18 months)

Trust vs mistrust Feeding

Early childhood

(2-3 years)

Autonomy vs shame and doubt 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

Conclusion: no clear data


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Family History

First children from

3 siblings He has 2 brothers

No family history

of psychiatrydissorders

PsychosexualHistory

Patient

psychosexualhistory isappropriate to his

gender. He realizesthat he is male andbehaves accordingto his gender.


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PATIENT

FEMALE

MALE


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Socio-Economic History

Economic Scale: Enough

Validity

Alloanamnesis : ValidAutoanamnesis : No

Valid Data


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Symptom

Role of

Function

18 November 201315 Nov1313 Nov13


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Appearance

A male, appropiate to his age, wear

complete clothes, bad self grooming.

State of ConsciousnessClear

Speech

Quantity : decrease

Quality : decrease


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BEHAVIOUR

Hypoactive

HyperactiveEchopraxia

Catatonia

Active negativism

Cataplexy

Streotypy

Mannerism

Automatism

BizarreCommand

automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotoragitation

CompulsiveAtaxia

Mimicry

Aggresive

ImpulsiveAbulia


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ATTITUDECooperative

Non-cooperative

Indiferrent

Apathy

Tension

Dependent

InfantileDistrust

Labile

Rigid

Passivenegativism

Catalepsy

Cerea flexibility

Excitement


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Mood

Happy

Dysphoric Euthymic

Elevated

Euphoria

Expansive Irritable

Cant be assesed

Affect

Appropriate

Inappropriate Restrictive

Blunted

Flat

Labile

Emotion


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Disturbance of Perception

Hallucination

Auditory (+)

Visual (+)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Undeferrentiated (-)

Illusion

Auditory (-)

Visual (-) Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Undeferrentiated (-)

Depersonalisation (-) Derealisation (-)


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Thought Progression

Quantity

Normal

Logorrhea

Blocking

Remming

Mutisme

Talk active

Quality

Irrelevan answer

Coherence

Incoherence

Flight of idea

Confabulation

Poverty of speech

Slow speech

Loosening of association

Neologisme

Circumtansiality

Tangential

Verbigrasi Perseverasi

Sound association

Word salad

Echolalia


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Content of thought

Idea of Reference Preocupation

Obsession

Phobia Delusion of Persecution

Delusion of Reference

Delusion of Envious

Delusion of Hipokondry

Delusion of magic-mystic

Delusion of Grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Delusion of Perception

Thought of Echo

ThoughtInsertion/withdrawal

Thought Broadcasting


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Thought process

Realistic

Non Realistic

Dereistic

Autistic


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Sensorium and Cognition

Level of education : Enough

General knowledge : Undeferrentiated

Orientation of time/

place/people/situation : Good Working/short/long memory: Cant be

assessed

Writing and reading skills : Can

t be assessed Visuospatial : Cant be assessed

Abstract thinking : Cant be assessed

Ability to self care : Decrease


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Impulse Control When Examined

Self control :

Bad

Patient response to examiners question:

Bad

Insight

Impaired insight Intelectual Insight

True Insight


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Internal Status

Conciousnes :

delirium

Vital sign: Blood pressure : 120/70 mmHg

Pulse rate : 80 x/mnt

Temperature : afebris

RR : 38 x/mnt

GDS : 79mg/dl


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Head : normocephali

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

pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax:

Cor : S1,2 Sound and normal

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

/-

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

Extremity : Warm acral, capp refill


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Motorik : Normotonus, coordination of movement not

good

Meningeal sign : negative

Physiologic reflect : +/+

Patologic reflect : -/-


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Mental Status

Behaviour: hypoactive

Attitude: non cooperatif

Mood: Disphoric

Afect: appropiate, restricted

Disturbenace of perception:halusination auditory (+) ,visual (+)

Tought progression: quality:coherence, slow speech,Quantity: remming

Content of tought : delusion ofmagic mistic, tought ofinsertion, and withdrawal

Form of tought: Non realistic Insight: impaired insight

impairment

Dont want to work anymore;

Social withdrawal;

impairment spare time;

Bad self grooming

Symptom

Irritable patient

Hit without any reason

Impulsive

Damage household appliances

Often angry without anyreason

Silent as a statue, suddenly hitthe cupboard

Solitaire

Talk alone and laugh alone

Often hear the sound of a

whisperOften complained of chest abdstomach feels hot

Patient fell no energy

Often sleep

Lazy to work

Cant communicate

Lazy to take a bath

Lost of appetite

Onset : 5 days ago

Stressor : family problem (there is a man that like his wife)


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Differential Diagnose

F05 Delirium Not Cause By Alcohol or OtherPsycoactive Drugs

F23.2 Acute Psycotic Disorder Lir Schizophrenia

F25.1 Schizoaffective Disorder Depression Type


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Multiaxial Diagnose

Axis I : F05 Delirium Not Cause By Alcohol or Other

Psycoactive Drugs

Axis II : F60.3 Personality type emotional unstable

Axis III : Suspect Gastritis

Axis IV : Family Problem(there is a man that like his wife)

Axis V : GAF admission 30-21


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Hospitalization

To establish an effective association between patients andcommunity support systems

Hospital treatment plans should be oriented toward practicalissues of self-care, quality of life, employment, and socialrelationships

ER

Inj. Haloperidol 1 amp IM

Room

Risperidone 2x2mg tab

Monitoring general appearance & vital sign

Psychosocial Therapy

Family-Oriented Therapies

Cognitive Behavioral Therapy


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Psycho-educationEducate the patient

That life is not always happy, and not always

sad.

life must go on, everyone has a problem,how well we fix it, depends on how we face

it.

provide motivation to work again


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Educate the patients family :

Explain about mental disorder. There are many factors cause

the symptoms, such as biommolecules imbalance in the brain, sowe need various aspects for the treatment.

Explain that depression caused by unfavorable life events, is

normally self limiting, and may be best treated with

cognitive/behavioral therapy rather than drugs.

Help the patient when he needs it.Education of the family to encourage communication and

understanding.

Educate the family for not to stay away from the patient, give

more love and close relationships with patients.

Tell them about the symptom if theresany side effect about the

drugs, and always control before run out medicine

Tell them about sign of reccurency of the mental illness


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Morning Report - 18-11-13 - Ana-lisa

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