Morning Report 15mar13

7/28/2019 Morning Report 15mar13

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Supervisor : dr. Sabar P Siregar Sp.KJ

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Autoanamnesis

Name :Mr. RAge :38 years old

Gender : MaleAddress :Temanggung Occupation :Not work Marital status :Married Religion :Moslem Last education :

Elementary School

Name :Mr. SAge :30 years old

Relation :Brother

Alloanamnesis

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CHIEF COMPLAINT

AFRAID

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4 months ago

Afraid, angry, sleep disorder (difficult tosleep), talk to himself, hear a sound that say

want to kill him

Poor grooming, Unemployed

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HISTORY OF PRESENTING ILLNESS

4 months ago

AfraidAngry

sleep disorder (difficult to sleep)talk to himselfhear a sound that say want to kill him

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PAST ILLNESS HISTORY

Psychiatry history

He comes for the first time

General medical history

Hypertension (+) Head injury (-)

Convulsion (-)

Asthma (-)

Allergy (-)

Drugs and alcohol abuse history and smoking history Alcohol consumption (-)

Tobacco consumption (-).

Drugs abuse (-)

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PRENATAL AND PERINATAL HISTORY

No valid datawhether the mother has sufficientnutricient during pregnancy and routine vitamincapsule during pregnancy

No valid datawhether she has stabile emotional

condition during this pregnancy

No valid datawhether every month she goes toprimary health care to check her pregnancy

No valid datawhether she has no significantmedical problem such as profuse vomitus , fever,high blood pressure, seizure, leukorea and bleeding

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EARLY CHILDHOOD PHASE

(0-3 YEARS OLD)

Psychomotoric

There were no valid data on patients growth and developmentsuch as: first time lifting the head, rolling over, sitting, crawling,standing, walking-running, holding objects in her hand, putting

everything in her mouth, holding objects in her handPsychosocial

There were no valid dataon which age patient started smilingwhen seeing another face, startled by noises, when the patientfirst laugh or squirm when asked to play, nor playing claps withothers

Communication

There were no valid dataon when patient started saying wordslike mom or dad, or talks.

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Emotion

There were no valid data of patients reaction whenplaying, frightened by strangers, when starting toshow jealousy or competitiveness towards other andtoilet training.

Cognitive There were no valid data on which age the patient

can follow objects, recognizing his mother,recognize his family members.

There were no valid data on when the patient firstcopied sounds that were heard, or understandingsimple orders

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Intermediate Childhood

(3-11 years old)

Psychomotor

No valid dataon when patients first time riding a tricycle or bicycle, ifpatient ever involved in any kind of sports.

Psychosocial

There were no data on patients gender identification, interaction with her

surroundings

Patient enter elementary school at 8 years old Communication

There were no valid data regarding patients ability to make friends in

school, and how many friends patient have during her schooling period.

Emotional

No valid data on patients adaptation under stress, any incidents ofbedwetting were not known.

Cognitive

Patient didnt graduated from 1st grade of elementary school

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Late Childhood & Teenage Phase Sexual development signs & activity

No valid data on when patient experience wet dream, hair on armpitsand pubis, etc

Psychomotor

No valid data if patient had any favourite hobbies or games, if patientinvolved in any kind of sports.

Psychosocial

No valid data if while growing up did he make many friends, how well

patient make any friends and how much friends. No valid data on when and how patients relationship with different

gender, if patient ever had any relationship with the opposite gender.

Emotional

No valid data if patient ever told friends or family regarding any

problems. No valid data if patient attempted to break the rules (truant schools

subject, fight with friends, bullying, etc) and consuming alcohol, smokeand drugs

Communication

No valid data on how well the relationship between patient with parents

and other family. 11


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Adulthood

Educational history

Patient hasnt graduated from elementary school

Marriage status

married, but not lived togehter.

Legal historyNo data

Social activity

have normal social activity

Current situationHe live with his mother and brother

Religion history

He prays daily until now

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Family History

There was not any history of psychiatric

disorder in his family, his father, mother,

brother, and his son

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Psychosexual history

Patient psychosexual history is appropriate

of his gender and attracted to girl

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15

:Female

:Male: RIP

: Mental illnes family ever


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Economic

scale:low

Socio-economic

historyAlloanamnesis

: valid

Autoanamnesi

: valid

Validity

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Mental State 15th March 2013

Appearance :

man , appropriate according to age, poor grooming

State of Consciousness

Clear

Speech:

Quantity : Enough

Quality : Enough

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Behaviour

Normoact ive

Hypoactive

Hyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

AutomatismBizzare

Command automatismMutism

Acathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive

Ataxia

Mimicry

AggresiveImpulsiveAbulia

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Attitude

Cooperative

Non-cooperative

Indiferrent

Apathy Tension

Dependent

Active

Passive

InfantileDistrust

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcitement

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Emotion

Mood

Euthymic

Hipothym Dysphor ic Euphoria

Elevated

Expansive Irritable

Cant be assesed

Affect

Appropr ia te

Inappropriate

Restrictive Blunted

Flat

Labile

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Disturbance of perception

Hallucination

Auditory (+) paranoid Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-) Somatic (-)

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

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Thinking thought 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 associationWord salad

Echolalia

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Thought Process content of thought

Idea of Reference

Preoccupation

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 Inf luence

Delusion of Passivity Delusion of Perception

Delusion of suspicious

Thought of Echo

Thought of Insertion/withdrawal

Thought of Broadcasting

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Thought process

Realistic

Non Realistic

Dereistic

Autism

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Sensorium and Cognition

Level of education : low

General knowledge : low

Orientation of time/place/people/situation:

enough/enough/enough/enough Working/short/long memory: enough

Writing and reading skills : low

Visuospatial : low

Abstract thinking : low

Ability to self care : low


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Self control : good

Patient response toexaminers question:

good

Impulse controlwhen examined

Impaired insight

Intelectual Insight True Insight

Insight

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Internal Status Conciousness: compos mentis Vital sign:

Blood pressure : 140/80 mmHg

Pulse rate : 62 x/mntTemperature : afebris

RR : 20 x/mnt

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Head : normocephali

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

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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Neurological status

Motoric : not tested

Physiological reflex : not tested

Pathological reflex : not tested

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Onset Mental state Impairment

4 months agoAfraid, angry, sleepdisorder (difficult tosleep), talk to himself,hear a sound that say

want to kill him

Attitude : tension- Mood :disforic-Affect : appropriate-Speech :

quantity : enough

quality :enough-Disturbacens of perception :auditory hallucination,-Thought content : delution ofreference

-Thought form : non realistic-Insight : true insight

2 months agooRole function: pooroPsychosocial: pooroAbility to self care:poor grooming

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Significant Finding Resume


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Multiaxial Diagnose

Axis I : F20.0 schizophrenia paranoidAxis II : R46.8 diagnosis axis II delay

Axis III : I.00 I.99 circulation system

disorder (hypertension)

Axis IV : problem with family (left by hiswife and son)

Axis V : GAF admission 30 - 21

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Hospitalization To establish an effective association between patients and community support

systems

Hospital treatment plans should be oriented toward practical issues of self-care,quality of life, employment, and social relationships.

FAMILY EDUCATION :

- explain to the patient about test results.

- explained to the patient's family know about this :

1. Severe mental disorder can be unsettled on anyone and can be caused by a numberof biological, social factors and organic2. Do not let the patient alone and treated like normal

3. Help if the patient need help but not passive.4. Not too much advise.

5. Families must understand the patient.

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Initial Therapy:

Lodomer 1 amp IM

-Room: Haloperidol 2 x 5 mg

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Morning Report 15mar13

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