Morpot Uki-june 14th 2014

8/12/2019 Morpot Uki-june 14th 2014

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MORNING REPORTSATURDAY, June 14th2014

SUPERVISORdr. Sabar P. Siregar, Sp.KJ


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Patient Identity

Autoanamnesis

Name : Mr. A

Sex : Male

Age : 22 years old

Address : Kebumen

Occupation : Labor

Marital State : Single

Alloanamnesis

Name : Mr. S

Sex : Male Relation : His father

Age : 52 years old


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Stressor

HIS MOTHERS DEATH

FALSE BELIEF


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PAT I E N T C O N F U S E , T R Y T O S U I C I D E , A N D

I RRI TAB I L I TY.

Reason patient was brought

to emergency room


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Present History

3 WEEKS AGO:QUIET

TRY TO SUICIDE

IRRITABILITY

RAMPAGE

TALK TO HIMSELF

TALK LESS

SLEEP DISTURBANCE

CANT SOCIALIZE WITH

OTHERS

INCREASE APPETITE

FEBRUARY 2014 : CONFUSE

QUIET

IRRITABILITY

CANT SOCIALIZE WITH

OTHERS

JANUARY 2014

FEEL GUILTY

CANT SOCIALIZE WITH

OTHERSBrought to

hospital


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Day of AdmissionJune, 14ths 2014

Patient was brought with the

complaints of:

QUIET

TRY TO SUICIDE

IRRITABILITY RAMPAGE

TALK TO HIMSELF

TALK LESS

SLEEP DISTURBANCE

Brought to hospital byHis father

CANT SOCIALIZE WITH OTHERS

INCREASE APPETITE


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Psychiatric History

Patient has no psychiatric problems

history before


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Head injury (-)

Hypertension (-)

Convulsion (-)

Asthma (-)

Allergy (-)

Generalmedical

history

Drugs consumption (-)

Alcohol consumption (+)

Cigarette Smoking (+)

Drugs and

alcohol abusehistory and

smoking history


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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotoric There were no valid data on patientsgrowth 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 hermouth(3-6 months)

Psychosocial 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 withothers (6-9 months)


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Communication

There were no valid data on when patient started bubbling. (6-9months)

Emotion

There were no valid data of patients reaction when playing,frightened by strangers, when starting to show jealousy orcompetitiveness towards other and toilet training.

Cognitive

There were no valid data on which age the patient can followobjects, recognizing her mother, recognize her family members.

There were no valid data on when the patient first copied soundsthat were heard, or understanding simple orders.


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INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)

Psychomotor No valid data on when patients first time playing hide and seek or if

patient ever involved in any kind of sports.

Psychosocial

No valid data regarding patient psychosocial. Communication

No valid data regarding patient ability to make friends at school and howmany friends patient have during her school period

Emotional

No valid data on patients emotional.

Cognitive

No valid data on patients cognitive.


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LATE CHILDHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA) No data on when patient first experience of wetdream, etc.

Psychomotor (NO VALID DATA)

No data if patient had any 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 patients emotional.

Communication (NO VALID DATA)

No valid data regarding patient ability to make friends at school and howmany friends patient have during his high school period


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ADULTHOOD

Educational History

He finished Junior High School

Occupational History

Hes worked

as a Labor. After 6month ago he is unworked.

Marital Status

Single

Criminal History No

Social Activity

He was friendly

Current Situation

He lives with his father andbrother. His father is a farmer

and his brother is jobless.

His Mother was died


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Eriksons stages

of psychosocial development

Stage Basic Conflict Important Events

Infancy

(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


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FAMILY HISTORY

Patient is the 2ndchild of 2 siblings

There is no psychiatry history in the family


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Male Female Patient Lives together

GENOGRAM


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PSYCHOSEXUAL HISTORY

Patient realizes that he is a male, andinterested in woman. His attitude is

appropriate as a male.


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Socio-economic history

Economic scale : low

Validity

Alloanamnesis : valid Autoanamnesis : valid


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Symptom

Role Function

January

2014

February

2014

Progression of Disorder

3 Weeks

Ago


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Mental State June 14 th2014

Appearance

A male, appropriate to his age, completely clothed

State of Consciousness

Cloudy

Speech Quantity : decrease

Quality : decrease


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BEHAVIOUR

Hypoactive

Hyperactive

Echopraxia

CatatoniaActive negativism

Cataplexy

Streotypy

Mannerism

AutomatismBizarre

Command automatism

Mutism

Acathysia

Tic

Somnabulism

Psychomotor agitation

Compulsive

Ataxia

MimicryAggresive

Impulsive

Abulia


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ATTITUDE

Non-cooperative

Indiferrent

Apathy

Tension Dependent

Passive

Infantile

Distrust

Labile

Rigid

Passive negativism

Stereotypy

Catalepsy

Cerea flexibilityExcited


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Emotion

Mood

Dysphoric Euthymic

Elevated

Euphoria

Expansive

Irritable

Agitation

Affect

Inappropriate

Restrictive

Blunted

Flat

Labile


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Disturbance of Perception

Hallucination

Auditory (+)

Visual (+)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Illusion

Auditory (-)

Visual (-)

Olfactory (-)

Gustatory (-)

Tactile (-)

Somatic (-)

Depersonalization (-) Derealization (-)


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Thought Progression

Quantity

Logorrhea Blocking

Remming

Mutism

Talk active

Quality

Irrelevant answer

Incoherence

Flight of idea

Poverty of speech

Confabulation

Loosening of association

Neologisme

Circumtansiality

Tangential

Verbigration

Perseveration

Sound association

Word salad

Echolalia


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Content of Thought

Idea of Reference Idea of Guilt

Preoccupation

Obsession

Phobia

Delusion of Persecution

Delusion of Reference

Delusion of Envious

Delusion of Hipochondry

Delusion of magic-mystic

Delusion of grandiose

Delusion of Control

Delusion of Influence

Delusion of Passivity

Delusion of Perception

Delusion of Suspicious

Thought of Echo Thought of insertion &

withdrawal

Thought of Broadcasting


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Form of Thought

RealisticNon Realistic

DereisticAutism

Cannot be evaluated


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Sensorium and Cognition

Level of education : finished junior high school

General knowledge : Cant be assessed

Orientation of time : good

Orientations of place : bad Orientations of people : good

Orientations of situation : bad

Working/short/long memory: good

Writing and reading skills : Cant be assessed Visuospatial : Cant be assessed

Abstract thinking : good

Ability to self care : good


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Impulse control whenexamined

Self control: good

Patient response toexaminers question:

good

Insight

Impaired insight

Intellectual Insight

True Insight


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Physical State

Consciousnes : clear consciousness

Vital sign :

Blood pressure : 130/80 mmHg

Pulse rate : 80 x/mnt

Temperature : 36.5 C

RR : 20 x/mnt


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Review System

Head : normocephali, mouth deviation (-)

Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax :Cor : S 1,2 regular

Lung : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm acral, capp refill


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Mental Status Impairment

- Behavior:hipoactive, Attitude:

cooperative

- Mood : dysphoric

-Affect : appropiate, stabile

-Disturbance of Perception:

hallucination visual (+) and

auditory (+)

-Thought of Progression:

Quantity: talk active

Quality: circumtansiality

-Content of Thought : idea of guilt,

delution of persecution

-Form of thought : non-realistic

QUIET

TRY TO SUICIDE

IRRITABILITY

RAMPAGE

TALK TO HIMSELF

TALK LESS

SLEEP

DISTURBANCE

CANT SOCIALIZE

WITH OTHERS

INCREASE APPETITE

Symptoms

Patient is a male, 22 years old, confuse, try to suicide and irritability.

RESUME - Day of admission


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F32.3 Severe Depression With Psychotic

Symptom

F25.1 Schizoaffective Type Depression

Differential Diagnosis


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Axis I : F32.3 Severe Depression With Psychotic

Symptom

F25.1 Schizoaffective Type Depression

Axis II : Z03.2 No Diagnose

Axis III : no diagnose

Axis IV : his mothers death, false belief

Axis V : GAF admission 20-11

Multiaxial Diagnosis


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PROBLEM RELATED TO THE PATIENT

1. Problem about patients life

His mothers death

False belief

2. Problem about patients biological state

There were abnormality imbalance neurotransmitter, increase of

serotonin, dopamine. So the patient needs psychopharmacology


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PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION)

To reduce 50% the symptoms :

QUIET

TRY TO SUICIDE

IRRITABILITY

RAMPAGE

TALK TO HIMSELF

TALK LESS

SLEEP DISTURBANCE

Response Remission Recovery


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RESPONSE PHASE

Target therapy :50% decrease of symptoms

Emergency departmentInj. Diazepam 10 mg IV

Inj. Haloperidol 5 mg IM Maintenance

Haloperidol 2x5 mg

Amitriptilin 3x25 mg

PlanningECT

Re-assess patient


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REMISSION PHASE

Target therapy : 100% remission of symptom

Inpatient management Continue the pharmacotherapy: haloperidol tab 2x5 mg, amitriptilin 3x25

mg Improving the patient quality of life :

Teach patient about her social & environment (interact with his family,socialize with her neighbor or friends, find a hobby to do on her spare time,and find a job that fits him well.)

Outpatient management Pharmacotherapy

Psychosocial therapy


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RECOVERY PHASE

Continue the medication, control to psychiatric

Rehabilitation :- Help patient to interact normally with his

family, friends, and neighbor

- Family education


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Thank you

Documents

Morpot Uki-june 14th 2014