Morning Report

Patient’s Identity1. Name : Mr. S2. Age : 74 years old3. Sex : Male4. Address : Kebumen5. Job : Unemployed6. Marital status : Widower7. Ethnicity : Javanese8. Educational status : Elementary

IdentityAlloanamnesis was conducted to :

I II

Name Mr. H Mrs. SAge 43 years old 40 years oldSex Male FemaleAddress Kebumen Kebumen status Son in law Daughter

Morning ReportMonday october 20th, 2014

Psychiatric history

Chief Complaint• Get easly anger

History of Present Illness3

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ital

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onPatient get easily angry and loaf around at midnight.

1 w

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tal a

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sionPatient didn’t

remember events and his family.

Hos

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dayPatient

destroyed households.

History of Past Illness• Psychiatric illness•There is no history of psychiatric illness in this patient

• General medical illness•There is no history of high fever, seizure, head trauma, but from blood pressure examination finding hypertension.

• Substance abuse•There is no history of alcohol and narcotic consumption.•Patient smokes cigarette 1pack/day

Depiction of Illness october 2014Symptoms

Role Function

Family History• There is no history of psychiatric

illness in patient’s family.• There is no history of high fever,

seizure, head trauma, or any other serious illness which needs hospitalization

Genogram

History of Personal Life• PrenatalHistory of pregnancyThere is no valid data => this pregnancy was plan

or no plan.History of birthThere is no valid data that tell birth process.

EARLY CHILDHOOD PHASE (0-3 YEARS OLD)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 objects in her hand(3-6 months)• putting everything in her mouth(3-6 months)

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 the patient first laugh or squirm when asked to play, nor

playing claps with others (6-9 months)

INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD) (NO VALID DATA)

Psychomotor • No valid data on when patient’s first time playing hide and seek

or if patient ever involved in any kind of sports.Psychosocial• No valid data on when patient’s child and his ability to

communicate other people.Communication No valid data on when patient’s child communication and his

ability to make friends at school. Emotional • No valid data on patient’s emotional.Cognitive▫Patient’s academic history wasn’t good, he not graduated from

elementary school.

LATE CHILHOOD & TEENAGE PHASESexual development signs & activity (NO VALID DATA)

▫No data on when patient wet dream etc.Psychomotor (NO VALID DATA)

▫No valid data on patient’s favourite hobbies or games, if patient involved in any kind of sports.

Psychosocial (NO VALID DATA) ▫No valid data regarding patient psychosocial.

Emotional (NO VALID DATA) ▫No valid data on patient’s emotional.

Communication (NO VALID DATA) ▫No valid data regarding patient ability to make friends at school

and how many friends patient have during his high school period

ADULTHOOD • Educational History

he not graduated from elementary school.

• Occupational historypreviously he worked as farmer.

• Marital Status widower

Criminal History No criminal history

Social Activity he is not an introvert

person and has a lot of friends.

Current Situationhe lives alone.

Erikson’s stages of psychosocial development

Stage Basic Conflict Important EventsInfancy(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

History of Personal Life• Psychosexual history and sexual development• Patient realizes that he is a male, and interested in

female. His attitude is appropriate as a male.• Patient get married at the 18 years old.

• Socioeconomic history• Patient doesn’t have any job now• Economic scale : low

• Degree of validity : valid

Morning ReportExamination

Physical Examination• General physical examination•General appearance : • Low nutritional status

•Vital sign : • BP : 160/90 mmHg• HR : 74x/m• to : afebris (36,8)• RR : 20x/m

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 <2”, edema (-)

Neurogical Examination• 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

Neurogical 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 (-)• Motoric examination• Normal movement, good coordination, normal strength

Mental State Examination• Appearance: • a man, appropriate to his age, completely clothed

• State of consciousness: foggy• Speech:• speak slowly, intonation and speech volume soft, unclear articulation, speech productivity poor

Mental State Examination• 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

Mental State Examination• Attitude:• Cooperative• Indiferrent• Apathy• Tension• Dependent• Passive• Infantile

• Labile• Rigid• Passive negativism• Stereotypy• Catalepsy• Cerea flexibility• Excited

Mental State Examination• Emotion:

Mood

• Dysphoric• Euthymic• Elevated• Euphoria• Expansive• Irritable• Agitation• Can’t be assesed

Affect

• Appropriate• Broad• Restrictive• Blunted• Flat• Labile

Mental State Examination• Disturbance of Perception

Hallucination

• Auditory (-) • Visual (-)• Olfactory (-)• Gustatory (-)• Tactile (-)• Somatic (-)

Illusion

• Auditory (-)• Visual (-)• Olfactory (-)• Gustatory (-)• Tactile (-)• Somatic (-)

Depersonalization (-) Derealization (-)

Mental State Examination• Thought Progression

Quantity

• Logorrhea• Blocking• Remming• Mutism• Talkative

Quality

• Irrelevant answer• Coprolalia• Incoherence• Flight of idea• Poverty of speech• Confabulation• Loosening of association• Neologisme• Circumtansiality• Tangential • Verbigration • Perseveration• Sound association• Word salad• Echolalia

Mental State Examination• 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

Mental State Examination• Form of Thought•Non Realistic• Dereistic• Autism• Cannot be evaluated

Sensorium and Cognition Level of education : unfinished elementary school General knowledge : bad Orientation of time : bad Orientations of place : bad Orientations of people : bad Orientations of situation : bad Working/short/long memory: bad Writing and reading skills : bad Visuospatial : bad Abstract thinking : bad Ability to self care : bad

Impulse control when examined• Self control: poor• Patient response to examiners question: good

Insight• Impaired insight• Intellectual Insight• True Insight

Morning ReportResume

Resume • Symptom: Patient get easly anger and destroyed

households.• Mental Status: • Behavior: hypoactive• Progression of thought: autism

• Impairment:• Patient can’t do the father’s role• Patient has a poor utilization of his leisure time• Impairment of social function

Symptom Grouping (Syndrome)Symptoms Syndrome Hypoactive

Psychotic syndrome

Non realisticDecrease of role function

hypertensiondemensia syndrome

Morning ReportDiagnosis

Differential Diagnosis• F 01.0 demensia vaskuler onset akut• F 01.1 demensia multi infark

Multiaxial Diagnosis• Axis I : F01.0 demensia vascular acute • Axis II: Z03.2 no axis II diagnosis• Axis III : no axis III diagnosis• Axis IV : no axis IV diagnosis• Axis V : GAF admission 40-31

Morning ReportManagement

Patient’s problems• Biological problemHypertension and oldery• Psychological problemshe didn’t remember events • Social problemWidower and lives alone

Management Planning• Hospitalization• Emergency DepartmentRisperidon 2mg 2x1• Wardsolanzapine• Psychotherapy

Response Remission

Recovery

Response Phase

• Target therapy : • 50% decrease of symptoms

• Emergency department• Risperidon 2mg 2x1

•Maintenance• Olanzapine

• Re-assess patient

Remission Phase

• Target therapy : • 100% remission of symptom

• Inpatient management• Risperidone 2mg 1ddI• 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• Pharmacotherapy• Psychosocial therapy

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

Thank You!