morning report 13

8/13/2019 Morning Report 13

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FK UKI and FK UGM


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I.PATIENT S IDENTITY

Name : Tn.MRAge : 45 years oldGender : MaleAddress : Depok, Sleman YogyakartaOccupation : UnemployedMarital status : Not MarriedReligion : MuslimLast education : Barchelor DegreeAlloanamnesisName : Mr. DAge : 27 years oldRelation : Brother in law


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II.CHIEF COMPLAINT

Not able to sleep in 2 days


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2 days ago

Not able to sleep Patient was restles Poor anger management (unreasonable angry) Threaten his father

Talk to him self, and irritable. Poor grooming, patien no desire to take a bath

15 years

ago

Uncontrelled Rage Not working

History of illness


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PAST ILLNESS HISTORY

Psychiatry history

First psychiatrydisorder about

15 years ago. Patients had a

history ofoutpatienttreatment and

taking medicationbut medication isnot adequate.

General medicalhistory

Hypertension (-)

Head injury (-) Asthma (-) Febrile seizure

(-) Hepatitis A (+)

Drugs and alcoholabuse history andsmoking history

Alcoholconsumption(-)

Tobaccoconsumption (+)

Drug use (-)


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PRENATAL DANPERINATAL

There is no data about his mother conditionwhen she is pregnant.

Patient delivered through normal delivery, atterm


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Emotion ( NO VALID DATA)

There were no valid data how patient showed normal reactionwhen playing, frightened by strangers, when starting to show jealousy or competitiveness towards other and toilet training.

Cognitive ( NO VALID DATA)

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 copiedsounds that were heard, or understanding simple orders.


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INTERMEDIATE CHILDHOOD (3-11 Y. O)Psychomotor

No valid data on when patients first time riding a tricycle or bicycle, if patientever involved in any kind of sports.

Psychosocial

There were no data on patients gender identification .

Communication

There were no valid data on socialization.

Emotional

No valid data on patients adaptation under stress

Cognitive

There were no valid data in terms of grades in school


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LATE CHILDHOOD & T EENAGE P HASE Sexual development signs & activity

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

PsychomotorThere were no valid data of favourite hobbies or games

PsychosocialBegin to have less friendsPatient claimed to have relationship with opposite gender.

EmotionalPatient expressed to mother regarding any problems.

Communication

No valid data.


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ADULTHOOD

Educational and Occupational History : patient s lasteducation is barchelor degree.Marital status : not marriedLegal History : Never been arrested or caught by

police.Social Activity : have a normal social activity.Current Situation : Living with his father.Religious History : Fair


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PSYCHOSEXUAL HISTORY

Patient psychosexual history is appropriate of hisgender and attracted to woman.


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GENOGRAM

:Female

:Male : RIP

: Patient


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Economic scale: low

Socio-

economichistory

Alloanamnesis : valid Autoanamnesis

: validValidity


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PROGRESSION OF ILNESS symptom

ole function

1997 2012


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III Mental State (13-12-2012)

Appearance :

Adult man, appropriate according to age, dressed

inappropriately

State of Consciousness

Clear

Speech: Quantity : Increased

Quality : normal


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BEHAVIOUR

HypoactiveHyperactiveEchopraxia

Catatonia Active negativismCataplexyStreotypy

Mannerism Automatism

Command automatism AcathysiaTicSomnabulism

Psychomotor agitationCompulsive AtaxiaMimicry

AggresiveImpulsive

Abulia


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ATTITUDECooperative

Non-cooperative

Indiferrent

Apathy

Tension

Dependent Active

Passive

InfantileDistrustLabile

RigidPassive negativismStereotypyCatalepsyCerea flexibility


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EMOTION

Mood

Dysphoric Euphoria Elevated Expansive

Irritable Cant be assesed

Affect

Appropriate

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


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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 association Word salad

Echolalia


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THOUGHT PROCESS CONTENT OF THOUGHT

Idea of reference

Preokupasi

Obsesi

Fobia

Delution of persecution

Delution of Reference

Delution of envious

Delution of hipokondri

Delusion of nihilistik

Delusion of control

Delusion of influence

Delusion of passivity

Delusion of perception

Thought of echoThought of insertion/withdrawal

Thought of broadcasting


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THOUGHT FORM

Form of Thought

RealisticNon RealisticDereisticAutistic


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SENSORIUMAND COGNITION

Level of education : enough

General knowledge : hard to be assessed

Orientation of time : enough

place : enough

people : enough

working/short/long memory: enough

Writing and reading skills : enough

Visuospatial : not evaluated

Abstract thinking : not evaluated

Ability to self care : poor


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Self control : enough Patient response to

examiners question: enoughImpulse controlwhen examined

Impaired insight Intelectual Insight True Insight

Insight


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IV. PHYSICAL EXAMINATION


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INTERNAL STATUS

Conciousness : compos mentis

Vital sign:

Blood pressure : 130/90mmHg

Pulse rate : 88x/mnt

Temperature : afebris

RR: : 18x/mnt


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Head : normocephali

Eyes : anemic conjungtiva -/-, icterik sclera -/-,

pupil isocore

Neck : normal, no rigidity, no palpable lymphnode

Thorax:

Chor : S1 and S2 Sound and normal

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

Abdomen : Pain - , peristaltic normal, thympany sound

Extremity : Warm a cral, capp refill


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NEUROLOGICAL STATUS

Motoric : not tested

Physiological reflex : not tested

Pathological reflex : not tested


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SIGNIFICANT FINDING RESUME

Onset 15 years ago

patient : Rage

2 days ago patient:

Not able tosleep

Rage Angry threaten his

father

Mental Status Euphoria mood Inappropriate

affect

AuditoryHalucination Delusion of

control Thought of

withdrawal Loosening of

assosiation

Impairment Role function:

inability to work. Spare time: talk to

himself Psychosocial : fair Ability to self care

: poor grooming


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DIFFERENTIAL DIAGNOSE

F20.0 Paranoid Schizophrenia

F25.0 Schizoaffective manic type


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VII. DIAGNOSTIC FORMULATION


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M ULTIAXIAL DIAGNOSE

Axis I : F20.0 Paranoid Schizophrenia

Axis II : Delayed

Axis III : No concomitant medical conditionAxis IV : Not working

Axis V : GAF 40 - 31


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MANAGEMENT THERAPY

Hospitalized : threatening his father.

Medication

-Initial Therapy: Lodomer 1 amp IM

-Room: Risperidon 2 x 2mg

THP 2 x 2mg (PRN)


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THERAPY

HospitalizedFamily education

Explain to his family about this patient mentaldisorderDescribes steps of treatmentFamily must maintain the patients drugsconsumption and routine doctor consultation, so

it will increase the efficacy of treatmentFamily must keep in touch with patientintensively.


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Ad vitam : Ad Malam

Ad functionum : Ad Malam

Ad sanationum : Ad


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Thank You

morning report 13

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