Morning Report Revision

8/10/2019 Morning Report Revision

1/46

MORNING REPORTSunday, October 26th, 2014


2/46

Patients Identity

1. Name : Mr. P

2. Age : 52 years old

3. Sex : Male

4. Address : Barang Wetan

5. Job : Farmer

6. Marital status : Married

7. Ethnicity : Javanese

8. Educational status : Junior High School


3/46


4/46

PSYCHIATRIC HISTORY

Morning Report

Sunday, October 26th, 2014


5/46

Chief Complaint

Wandering around and not coming home.


6/46

Stressor

Unknown


7/46

History of Present Illness

1 Week Ago

The patient prayed from night to early morning and fell

asleep. After he woke up, he told his wife that he had a

dream that told him to opened a grave in his village.

Then, he and some of villagers came to the location inhis dream but there was nothing but a garden there. He

came back home and started to locked himself in the

room. He read Al-Quran and talked randomly by

himself. He only left his room to eat and take a bath. Hedidntgo to work.


8/46

Contd

1 Days Ago

The patient tried to killed himself with knive but it can

be prevented by his brother. He couldnt sleep at night

and he was wandering around outside his house and

found in a police station in the next morning.


9/46

History of Past Illness

Psychiatric illness There is no history of psychiatric ilness

General medical illness

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

Substance abuse History of smoking

No history of use of alcohol and drugs


10/46

Depiction of Illness

2014

Symptoms

Role

Function


11/46

Family History

There is no history of psychiatric illness in patients family

There is no history of high fever, seizure, head trauma, or

any other serious illness which needs hospitalization


12/46

GenogramDescription :: man

: : woman

: death

: patient


13/46


14/46


15/46

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)

Psychomoto r (NO VALID DATA)

No valid data on when patientsfirst time playing hideand seek or if patient ever involved in any kind ofsports.

Psychosocial (NO VALID DATA)

No valid data when patient child and his ability to

communicate with other people.Commun icat ion (NO VALID DATA)

No valid data on Patients ability to make friends atschool.

Emotional (NO VALID DATA)

No valid data on patientsemotional.

Cogn itiv e (NO VALID DATA)

No valid data on patient academic history.


16/46

LATE CHILHOOD & TEENAGE PHASE

Sexual development sig ns & act ivit y (NO VALID DATA)

No data when patient wet dream etc.

Psychom otor (NO VALID DATA)

No valid data on patientsfavourite hobbies or games, if

patient involved in any kind of sports.

Psychosoc ial (NO VALID DATA)

No valid data regarding patient psychosocial.

Emotional (NO VALID DATA)

No valid data on patientsemotional.

Commun ication (NO VALID DATA)

No valid data regarding patient ability to make friends at

school and how many friends patient have during his

junior high school period


17/46

ADULTHOOD

Educat ional History

Hes graduated from

junior high school.

Occupat ional history

He worked as a farmer.

He had a goodrelationship with his

fellows. But now he

wont go to work.

Marital Status

Married

Criminal History

No criminal history

Social Activity

He is an outgoing person and

he has some close friends

Current Situation

He lives with his wife and

children


18/46

Eriksons stages of psychosocial developmentStage Basic Conflict Important Events

Infancy

(birth to 18 months)Trust vs mistrust Feeding

Early childhood

(2-3 years)

Autonomy vs shame and

doubtToilet 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


19/46

History of Personal Life

SOCIO-ECONOMIC HISTORY

Economic scale : low

VALIDITY

Alloanamnesis : valid

Autoanamnesis : not valid

Patient realizes that he is a male Has interests to female

His attitude is appropriate as a male


20/46EXAMINATION

Morning Report



21/46

Physical Examination

General physical examination

General appearance :

Good nutritional status

Vital sign :

BP : 160/100 mmHg

HR : 100x/m

to : afebris

RR : 20x/m


22/46

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


23/46

Neurogical Examination

Cranial nerves examination:

The cranial nerves examination cant be assesed because the patient is

hyperactive and non cooperative

CN I : cant be assesed

CN II : cant be assesed CN III,IV,VI : cant be assesed

CN V : cant be assesed

CN VII : cant be assesed

CN VIII : cant be assesed CN IX : cant be assesed

CN X : cant be assesed

CN XI : cant be assesed

CN XII : cant be assesed


24/46

Neurogical Examination

The neurogical examination cant be assesed because the

patient is hyperactive and non cooperative

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


25/46

Mental State Examination

Appearance:

a man, appropriate to his age, completely clothed

State of consciousness: foggy

Speech:

speak not spontaneously, intonation and speech

volume loud, unclear articulation, speech

productivity is poor



26/46


Behavior Hypoactive

Hyperactive

Echopraxia

Catatonia

Active negativism

Cataplexy

Streotypy

Mannerism

Automatism

Bizzare Command automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive Ataxia

Mimicry

Aggresive

Impulsive

Abulia


27/46


28/46


Emotion:

Mood

Dysphoric

Euthymic

Elevated

Euphoria

Expansive Irritable

Agitation

Cant be assesed

Affect

Appropriate Inappropriate

Restrictive

Blunted

Flat Labile


29/46


Disturbance of Perception

Hallucination

Auditory (-)

Visual (+)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Depersonalization (-) Derealization (-)


30/46


31/46

Cont 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 & withdrawal

Thought of Broadcasting


32/46

Cont

Form of Thought

Non Realistic

Dereistic

Autism Cannot be evaluated


33/46

Sensorium and Cognition

Level of education : finished junior high school

General knowledge : unknown

Orientation of time : bad

Orientations of place : bad

Orientations of people : bad

Orientations of situation : bad

Working/short/long memory : unknown

Writing and reading skills : unknown

Visuospatial : unknown

Abstract thinking : unknown

Ability to self care : bad


34/46

Impulse control when examined

Self control: bad

Patient response to examiners question: bad


35/46

Insight Impaired insight

Intellectual Insight

True Insight


36/46RESUME

Morning Report



37/46

Resume A male, 52 years old, appropriate according to her age

Symptom: Patient liked to talked by himself and locked up the room since 1weeks ago.

Mental Status:

Behavior: Hyperactive

Attitude: Infantile and labile

Mood: Dysphoric, Labile

Progression of thought: Remming. Poverty of speech, irrelevant answer,

word of salad.

Hallucination: Visual

Impairment:

Patient is unable to perform daily activities well

He cant spend his free time well

Impairment of social function

Patient cant take care of himself well


38/46DIAGNOSIS

Morning Report



39/46


40/46

Multiaxial Diagnosis

Axis I : F 05 Delirium due to Known Physiological

Condition

Axis II : Z03.2 No axis II diagnosis

Axis III : Hypertension

Axis IV : None

Axis V : GAF admission 20-11


41/46MANAGEMENT

Morning Report



42/46

Management Planning

Hospitalization Patient tried to kill himself

Patient wont perform a job

Patient is unable to perform daily activities well

Impairment of social function Patient cant take care of himself well

Emergency Department

Haloperidol 5mg im

Diazepam 5 mg iv

Wards

Haloperidol 5 mg po 2dd1

Finding about the underlying

causes

Response Remission Recovery


43/46

Response Phase

Target therapy : 50% decrease of symptoms

Maintenance Haloperidol 5 mg po 2dd1

Re-assess patient


44/46

Remission Phase

Target therapy : 100% remission of symptom

Inpatient management

Haloperidol 5 mg 2 dd I

Improving the patient quality of life : Teach patient about his social & environment (interact

with his family, socialize with his neighbor or friends, finda hobby to do on his spare time)

Outpatient management Pharmacotherapy

Psychosocial therapy


45/46

Recovery Phase

Continue the medication, control to psychiatric

Rehabilitation:

- Help patient to find a hobby,

- Help patient to interact normally with his

family and neighbor

- Family education


46/46

THANK YOU!

Morning Report Revision

Documents