Morning Report - 23 April14

8/19/2019 Morning Report - 23 April14

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MORNING MORNING REP O

RT

REP ORT W ednesday , Apr il 23r d 2014

S u p e r v i s

o r :

D r. S a b a r S i r e

g a r, S p K

J


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Patient IdentityPatient Identity


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Relatives IdentityRelatives Identity


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RReasoneason patient ro!"#t topatient ro!"#t to

e$er"en%y roo$&e$er"en%y roo$&


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'tressor'tressor

'till !n%lear


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(ay o) Ad$ission(ay o) Ad$ission

April 20 2014


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PPsy%#iatri%sy%#iatri% *istory*istory


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*ospitali+ation *istory


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Emotion (NO VALID DATA) T#ere ere no valid data o) patient9s rea%tion #en playin",

)ri"#tened y stran"ers, #en startin" to s#o 7ealo!sy or%o$petitiveness toards ot#er and toilet trainin":

Cognitive (NO VALID DATA) T#ere ere no valid data on #i%# a"e t#e patient %an )ollo

o7e%ts, re%o"ni+in" #is $ot#er, re%o"ni+e #is )a$ily $e$ers: T#ere ere no valid data on #en t#e patient rst %opied

so!nds t#at ere #eard, or !nderstandin" si$ple orders:


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INTERME(IATE .*I(*OO( /311 -EAR'INTERME(IATE .*I(*OO( /311 -EAR'

O(O(

Psychomotor (NO VALID DATA)

No valid data on #en patient9s rst ti$e playin" #ide and see6or i) patient ever involved in any 6ind o) sports:

Psychosocial (NO VALID DATA)

No valid data on t#e patient9s psy%#oso%ial develop$ent

CommunicationThe patient has an easy going personality, according to

his father the patient has got quite a lot of friends.

Emotional (NO VALID DATA)

No valid data on patient9s adaptation !nder stress, any in%idents

o) edettin" ere not 6non:

Cognitive (NO VALID DATA)

No valid data on personality patient9s %o"nitive:


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ATE .*I(*OO( ; TEENAGE P*A'EATE .*I(*OO( ; TEENAGE P*A'E

Seual !evelo"ment signs # activity (NO VALID DATA) No data on #en patient9s et drea$ et%:

Psychomotor (NO VALID DATA) No data i) patient #ad any )avo!rite #oies or "a$es, i) patient

involved in any 6ind o) sports:

Psychosocial (NO VALID DATA)• No valid data on t#e patient9s psy%#oso%ial develop$ent

Emotional (NO VALID DATA)

No valid data on patient9s rea%tion on playin", s%ared, s#oed 7ealo!sly or %o$petitiveness

Communication• The patient had no diculty to communicate with the family

and friends, he was quite open about his problems to hisbrother and his parents:


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A(


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Eri6son9s sta"es o)Eri6son9s sta"es o)

psy%#oso%ial develop$entpsy%#oso%ial develop$entStage Basic Conict Important !ents

In)an%y/irt# to 1= $ont#s

Tr!st vs $istr!st >eedin"

Early %#ild#ood/23 years

A!tono$y vs s#a$e anddo!t

Toilet trainin"

Pres%#ool/3? years

Initiative vs "!ilt E@ploration

'%#ool a"e/11 years

Ind!stry vs in)eriority '%#ool

Adoles%en%e

/121= years

Identity vs role %on)!sion 'o%ial relations#ips

-o!n" Ad!lt#ood/1540 years

Inti$a%y vs isolation Relations#ip

Middle ad!lt#ood/40? years

Generativity vs sta"nation Wor6 and parent#ood

Mat!rity/? deat#

E"o inte"rity vs despair Ree%tion on li)e


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>a$ily *istory>a$ily *istory

0Patient is t#e 1st %#ild o!t o) 2silin"s:

0Psy%#iatry #istory in t#e )a$ily /


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• Suffers from

mental illness

• Female

• Male

GENOGRAMGENOGRAM


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Psy%#ose@!al *istoryPsy%#ose@!al *istory


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Symptom

"olefunction

#rogression of $isorder

2 years

agonow4 years

ago


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Mental 'tateMental 'tate

AprilApril 2020 20142014


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•*ypoa%tive•%yperacti!e•E%#opra@ia

•.atatonia•&cti!e negati!ism•.ataple@y•'treotypy

•Manneris$•A!to$atis$•Bi+arre

•.o$$anda!to$atis$•M!tis$

•A%at#ysia• Ti%•'o$na!lis$•Psy%#o$otor a"itation•.o$p!lsive•Ata@ia•Mi$i%ry•&ggresi!e•I$p!lsive

•A!lia

Be#avio!rBe#avio!r


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• 'on(cooperati!e

• Indi)errent• Apat#y• Tension• (ependent

• Passive

•In)antile•$istrust•aile

•Ri"id•Passive ne"ativis$•'tereotypy•.atalepsy

•.erea e@iility•E@%ited

Attit!deAttit!de


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E$otionE$otion


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(ist!ran%e o) per%eption

(epersonali+ation / (ereali+ation /


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T#o!"#t pro"ression


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.ontent o) t#o!"#t

• Idea o) Re)eren%e

• Idea o) G!ilt

• Preo%%!pation

• Osession

• P#oia

• (el!sion o) Perse%!tion

•

(el!sion o) Re)eren%e• (el!sion o) Envio!s

• (el!sion o) *ipo%#ondry

•

(el!sion o) $a"i%$ysti%

• (el!sion o) "randiose

•

(el!sion o) .ontrol• (el!sion o) In!en%e

• (el!sion o) Passivity

•(el!sion o) Per%eption

• (el!sion o) '!spi%io!s

• T#o!"#t o) E%#o

• T#o!"#t o) Insertion ;it#draal

• T#o!"#t o) Broad%astin"

• Can not be assessed


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>or$ o) t#o!"#t

•Realisti%•Non Realisti%•(erealisti%

•&utism


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Sensorium and Cognition

evel o) ed!%ation & C!nior #i"# s%#ool General 6noled"e & %an9t e assessed Orientation o) ti$e & ad

Orientations o) pla%e & ad Orientations o) peoples & ad Orientations o) sit!ation & ad Wor6in"Ds#ortDlon" $e$ory& %an9t e

assessed

Writin" and readin" s6ills & %an9t eassessed

is!ospatial & %an9t e assessed Astra%t t#in6in" & %an9t e assessed Aility to sel) %are & ad


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#hysical Status

.ons%io!snes & %o$pos $entisital si"n &

◦ Blood press!re & 100D0$$*"

◦ P!lse rate & ==@D$nt◦ Te$perat!re & A)eris

◦ RR & 22@D$nt


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*ead & nor$o%ep#ali, $o!t# deviation /

Eyes & ane$i% %on7!n"tiva /D, i%teri% s%lera /D, p!pil

iso%ore

Ne%6 & nor$al, no ri"idity, no palpale ly$p# nodes

T#ora@&

.or & ' 1,2 re"!lar

!n" & vesi%!lar so!nd, #ee+in" D, ron%#iD

Ado$en & Pain / , nor$al peristalti%, ty$pany so!nd

E@tre$ity & War$ a%ral, %app rell F2, $otori% stren"t#

Ne!rolo"i%al e@a$ & not e@a$ined

5

5

5

5


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)entalStatus

Impairment


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(iHerential (ia"nosis

>20:2 .atatoni% '%#i+op#renia>2?:0 '%#i+oaHe%tive Mani% Type


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Prole$ related to t#eProle$ related to t#e

patientpatient


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PANNING MANAGEMENTPANNING MANAGEMENT

Inpatient +hospitaliation-0 Be#avio!r& #ypera%tive, a""ressive, a%tive ne"ativis$

0 Attit!de&non%ooperative, distr!st

0 Mood & A"itation, aHe%t & appropriate

0 T#o!"#t pro"ress& o"orr#ea, >li"#t o) ideas; loosenin" o)asso%iation


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RE'PON'E P*A'ERE'PON'E P*A'E

Target therapy ?0J de%rease o) sy$pto$s/s!dden ra$pa"e ,tal6in" "ieris#,restless,#ypera%tive,a""ressive,

non%ooperative, i"#t o) ideas; loosenin" o) asso%iation

mergency departmentAntipsy%#oti%s &In7: *aloperidol ?$" IM(ia+epa$ 1 a$p I

#lan of TherapyE.TAntipsy%#oti% & *aloperidol 2@2 $"

"e(assess patient

REMI''ION P*A'EREMI''ION P*A'E


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REMI''ION P*A'EREMI''ION P*A'ETarget therapy

/001 remission of symptom /s!dden ra$pa"e,tal6in" "ieris#, restless,#ypera%tive,a""ressive,non%operative,i"#t o) ideas; loosenin" o)asso%iation

Inpatient management1: .ontin!e t#e p#ar$a%ot#erapy2: I$provin" t#e patient 8!ality o) li)e y doin" so%ialvo%ational s6ills trainin" s!%# learn "ood #y"iene,

prepare $eals and #ave etter %o$$!ni%ation:

2utpatient management1: P#ar$a%ot#erapy2: Psy%#oso%ial t#erapy


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T *ANK - O<T *ANK - O

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Morning Report - 23 April14