Morning Report

MORNING REPORTSunday March 15th , 2015Supervisor:Dr. Sabar Siregar, Sp. KJ

I

Patient’s Identity

1. Name : Mr. H

2. Age : 29 years old

3. Sex : Male

4. Address : Kalibanger,Temanggung

5. Job : Employed

6. Marital status : Single

7. Ethnicity : Javanese

8. Educational status : Junior High School

Guardian IdentityAlloanamnesis was conducted to :

1. Name : Mr. Y

2. Age : 39 years old

3. Sex : Male

4. Address : Gemawang, Temanggung

5. Job : Farmer

6. Marital status : Married

7. Ethnicity : Javanese

8. Relation : Father

Reason brought to hospital

Patient was brought by his family because he did not want to work since one year ago.

Stressor

He work at a big company, and he expect that he will success with his job, but at reality he couldn’t met his expectation.

Progression of Illness(Alloanamnesis and autoanamnesis)

2014 (1 year ago)

Patient started not to work since one year ago, Patient felt that there was somebody look at him. He felt that the other people would do something harmed to him. He felt that his life uncomfortable. He think that the other people can read his mind. The patient hear some whisp which threatened him. He believe that some artist knew him. Sometimes the patient wait some artist arrived to met him.

15th March 2015 (day of admission)

Patient was brought by his family to RSJSM, because he didn’t want to work and disturbing the other people near him. He spit out the other people near him. Sometimes he broke some stuff too.

History of Past Illness

Psychiatric illness There is no history of psychiatric illness General medical illness There is no history of high fever, seizure,

head trauma, or any other serious illness which needs hospitalization

Substance abuse The patient smoke a pack of cigarette in a

day The patient also consume alcohol

Family History

There is no history of psychiatric illness in her family.

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

Progression of Illness

Symptoms

Role Function

2014

2015

GENOGRAM

History of Personal Life

Prenatal and perinatal Patient’s mother was 22 years old

during pregnancy and labor, and had no illness

Patient was delivered by normal labor, and by traditional birth attendants

Patient consumed pure breast milk for 6 months

History of Personal Life

Early childhood phase (0-3 years old) Psychomotor

There was no valid data in patient’s psychomotor aspect (such as tilting the body, supine to prone, sitting, standing, walking, smiling, holding her own hand, scoop up object, holding pencil and pilling up two objects)

Psychosocial There was no valid data in patient’s psychosocial aspect (such as replying to

smile, smiling when seeing interesting object, playing cilukba, knowing her family members and pointing what she wanted without crying)

Communication There was no valid data in patient’s communication aspect (such as bubbling,

cooing, making sounds without meaning, telling 2-3 syllables without meaning and calling mama/papa)

Emotion There no valid data in patient’s emotion aspect (such as when patient playing,

frightened by strangers, starting to show jealousy or competitiveness towards other, and toilet training)

Patient didn’t pee or defecate in her pants when she was two years old Cognitive

There was no valid data in patient’s cognitive aspect (such as copying sounds that she heard for the first time and understanding simple orders)

History of Personal Life Intermediate childhood phase (3-11 years old)

PsychomotorThere is no valid data on when patient’s first time playing hide and seek or if patient ever involved in any kind of sports.

PsychosocialThere was no valid data in patient’s psychosocial data (such as developing initiative capacity, seeking for socialization, starting social interaction with others, developing self worth in own’s abilities and competitive capacity).

CommunicationThere is no valid data on patient’s communication data (ability to communicate with same age friends/peers, and express needs and wants).

EmotionThere is no valid data on patient’s emotion data (such as ability to experience physiologic response due to emotion)

CognitiveThere is no valid data in patient’s cognitive data (such as knowlegde, understanding , application of knowledge, anylisis, and evaluation abilities)

History of Personal Life Late childhood and teenage phase (11-18 years old)

PsychomotorThere is no valid data on patient’s psychomotor data (such as favorite activities or games, if patient involved in any kind of sports).

PsychosocialThere is no valid data in patient’s psychosocial data

(such as seeking for self identity)Communication

There is no valid data in patient’s communication data (ability to interact with peers – others, ability to discuss subjects and question, tolerate opposite opinions)

EmotionThere is no valid data in patient’s emotion data

(ability to control physiologic response due to emotion; such as palpitation, increased sweating when angry)

Cognitive

History of Personal Life Adulthood phase (18 years old-now)

Educational The patient didn’t continue to senior high school, he finish his study

on junior high school Occupational

Employee Marital status

Patient is single Criminal

He has no criminal history Current situation

Patient lives with his family.

Erikson’s stages of psychosocial development

Examination

Morning Report

Physical Examination

General physical examination

General appearance : well groomed, well nourished

Vital sign : BP : 130/90 mmHgHR : 84x/minto : afebrisRR : 20x/min

General physical examination

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 <2”, edema (-)

Neurological examination

Level of Consciousness : compos mentis, E4V5M6 (15)

General Appearance : Body posture : normal Abnormal movement : no abnormal

movement Walking style : normal


Cranial nerves examination: CN I : in normal finding CN II : in normal finding CN III,IV,VI : in normal finding CN V : in normal finding CN VII : in normal finding CN VIII : in normal finding CN IX : in normal finding CN X : in normal finding CN XI : in normal finding CN XII : in normal finding


Motoric Upper extremities: tonus (+), trophy : eutrophic, power

of movement : shoulder joint : 5, elbow joint : 5, wrist joint : 5, radial nerve function : 5, ulnar nerve function : 5, median nerve function : 5

Lower extremities: tonus (+), trophy : eutrophic, power of movement : hip joint : 5, knee joint : 5, ankle joint : 5

Sensorium DCML system : proprioception, fine touch : no

abnormalities AL system : vibration, temperature, crude touch, pain :

no abnormalities

Neurological examination 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 (-), clonus -/- Meningeal sign

Neck stiffness (-), brudzinski neck sign (-), brudzinski contralateral leg sign (-), kernig sign (-)

Cerebellum function Adhyadokokinesia (-), romberg test (-), finger to nose test

(no abnormalities), tip to toe walk (no abnormalities)

Morning Report

Mental State Examination

General Appearance

A man, age 29 years old, appropriate to his age, looked tense, wearing clothes, well groomed and well nourished

Orientation

Time : good People : good Place : good Situation : good

ConsciousnessConsciousness• Clear

Behavior

Attitude

Emotion

Disturbance in Perception

Progression of Thought

Content of Thought

• Idea of Reference

• Preoccupation

• Obsession

• Phobia

• Fantasy

• Delusion of Persecution

• Delusion of Reference

• Delusion of Envious

• Delusion of Hypochondriac

• Delusion of Magic-mystic

• Idea of suicidal

• Idea of Reference

• Preoccupation

• Obsession

• Phobia

• Fantasy

• Delusion of Persecution

• Delusion of Reference

• Delusion of Envious

• Delusion of Hypochondriac

• Delusion of Magic-mystic

• Idea of suicidal

• Delusion of Grandiose

• Delusion of Control

• Delusion of Religion

• Delusion of Influence

• Delusion of Passivity

• Delusion of Suspicious

• Idea of Suspicion

• Thought of Echo

• Thought of Insertion

• Thought of withdrawal

• Thought of

Broadcasting

Form of Thought

Non - realistic

Cognitive Function

Level of education : finished Junior High School

General knowledge : good Working/short/long memory : good Writing and reading skills : good Visuospatial : good Abstract thinking : good Ability to self care : good

Impulse Control When Examined

Self control: poor Patient response to examiners question: good

InsightInsight• Impaired insight

Morning Report

Resume

Symptom: Mental Status: Impairment:

• Didn’t work• Delusion of Suspicious (The

patient felt that the other people would do harm to him)

• Delusion of grandious (The patient felt that he knew some artists)

• Tought of broadcasting (The patient tought that the other people could read his mind)

• Behavior:Normoactive, Bizzare

• Mood : Euthymic,

• Affect : Inappropriate, Flat, Stabil

• Progression of Thought:Remming, Coherent, Relevant

• Content of thought : Delusion of Suspicious, Delusion of Grandiose, tought of broadcasting

• Form of thought : non-realistic

• Insight: Impaired insight

• Patient lose interest in his job

A man, 29 years old, single, employed, didn’t work, change in behavior, grandious, suspicious to other people

Morning Report

Diagnosis

Syndrome

SchizophreniasyndromeParanoid Syndrome

Auditorik Halutination

Thought of broadcasting

Delusion of suspicious

Delusion of GrandiousManiac syndrome

Differential Diagnosis

F20.3 Schizophrenia Paranoid F25.0 Schizoaffective maniac type

Multiaxial Diagnosis

Axis I : F20.3 Schizofrenia Paranoid Axis II : F60.0 Paranoid personality type Axis III : No diagnosis Axis IV : Stressor: Problem with his job Axis V : GAF admission 40-31

Patient’s problems

Biological problem Positive symptoms because of an

imbalance in dopamine activity, receptors and sensibility in the post synaptic neuron.

Psychological problems Conflict with his job

Social problem He can’t socialize well with others

Morning Report

Management

PLANNING MANAGEMENT

Management Planning

HospitalizationPatient was hospitalized.Patient Spit to other people

Emergency Department• Inj. Haloperidol 5 mg 1 Amp IM• Inj. Diazepam 5 mg 1 Amp IV

Response Phase

Target Therapy• 50% decrease of symptoms

Maintenance Therapy Haloperidol 2 x 2 mg

Remission phase

Target therapy : 100% remission of symptom

Inpatient management Haloperidol tab 5mg 2x1 Improving the patient quality of life :

Teach patient about his social & environment (interact with his family, socialize with his neighbor or friends, find a hobby to do on his spare time)

Outpatient management Continuation of pharmacotherapy Psychosocial therapy

Recovery Phase

Continue the medication, control to psychiatrist Rehabilitation :

- Consult to psychologist to help patient finding a hobby

- Help patient to interact normally with his family and neighboor

Family Education

Mental disorders can be controlled by medicines, so it is important to take the medicines routinely

Treat patient like you treat any other people

Help patient if he should be helped Don’t push patient to understand the

family, but his family that has to understand him

Don’t be too emotional to patient

THANK YOU!

Documents

Morning Report