morning report psikiatri

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Morning ReportTuesday, October 21

st

, 2014


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PSYCHIATRIC HISTORY

Morning Report

Tuesday, October 21st, 2014


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Chief Complaint

Laughing and talking to himself


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Stressor

The patients girlfriend had already got

married with someone else.


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History of Present Illness

The patient came with his father. His father explains that

He likes to talk and laugh to himself

He cant communicates well with others

His father told that the patient had a relationship with a

woman, but it turned out that his girlfriend had already

married. The patient didnt take his medicine in this pastmonth. Hes unable to perform daily activities well.


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History of Past Illness

Psychiatric illness

The patient was hospitalized once in 2011

General medical illness

There is no history of high fever, seizure, head

trauma, or any other serious illness which

needs hospitalization

Substance abuse History of smoking

No history of use of drugs


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Depiction of Illness

2009 2014Symptoms

Role

Function


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Family History

There is no history of psychiatric illness in

patients family

There is no history of high fever, seizure,

head trauma, or any other serious illness

which needs hospitalization


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Genogram

Description :

: man : divorced

: : woman

: death

: patient


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History of Personal Life

Prenatal

History of pregnancy

The pregnancy was planned

History of birthHe was born in home with the help of dukun beranak


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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)

Psychomotor (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 his hand(3-6 months)

putting everything in his 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)


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INTERMEDIATE CHILDHOOD PHASE (3-11 YEARS OLD)

Psychomotor (NO VALID DATA)

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)

No valid data when patient child and his ability to

communicate with other people.Communication (NO VALID DATA)

No valid data on Patientsability to make friends at school.

Emotional (NO VALID DATA)

No valid data on patientsemotional.

Cognitive (NO VALID DATA)

No valid data on patient academic history.


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LATE CHILHOOD & TEENAGE PHASE

Sexual development signs & activity (NO VALID DATA)

No data when patient wet dream etc.

Psychomotor (NO VALID DATA) No valid data on patientsfavourite 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 patientsemotional.

Communication (NO VALID DATA)

No valid data regarding patient ability to make friends at school

and how many friends patient have during his junior high school

period


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ADULTHOOD

Educational History

Hes graduated from

elementary school.

Occupational history

Previously he worked as a

laborer. He had a goodrelationship with his

fellows. But now he wont

do anything.

Marital Status

Single

Criminal History

No criminal history

Social Activity

He is an introvert person but

he has a few close friends

Current Situation

He lives with his parents and

grandfather


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Stage Basic Conflict Important Events

Infancy

(birth to 18 months)Trust vs mistrust Feeding

Early childhood

(2-3 years)

Autonomy vs shame and

doubtToilet 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

Eriksons stages of psychosocial development


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History of Personal Life

SOCIO-ECONOMIC HISTORY

Economic scale : low

VALIDITY

Alloanamnesis : valid

Autoanamnesis : not valid

Patient realizes that he is a male Has interests to female

His attitude is appropriate as a male


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EXAMINATION

Morning Report



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Physical Examination

General physical examination

General appearance :

Good nutritional status

Vital sign :

BP : 120/80 mmHg

HR : 100x/m

to : afebris

RR : 20x/m


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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


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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


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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


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Mental State Examination

Appearance:

a man, appropriate to his age, completely clothed

State of consciousness: clear

Speech:

speak spontaneously, intonation and speech

volume loud, clear articulation, speech

productivity abundant



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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


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Attitude: Non-cooperative

Indiferrent

Apathy

Tension

Dependent

Passive

Infantile

Labile

Rigid

Passive negativism

Catalepsy

Cerea flexibility

Excited


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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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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


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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


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Form of Thought

Non Realistic

Dereistic

Autism Cannot be evaluated


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Sensorium and Cognition

Level of education : finished elementary school

General knowledge : good

Orientation of time : good

Orientations of place : good

Orientations of people : good

Orientations of situation : good

Working/short/long memory: good

Writing and reading skills : good

Visuospatial : good

Abstract thinking : good

Ability to self care : bad

Impulse control when


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Impulse control when

examined Self control: bad

Patient response to examiners question: good


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Insight

Impaired insight

Intellectual Insight

True Insight


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RESUME

Morning ReportTuesday, October 21st, 2014


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Resume

A male, 25 years old, appropriate according to her age

Symptom: Patient liked to talked and laughed to himself alone

since 1 month ago, Patient cant relate well socially, unable toperform daily activities well

Mental Status: Behavior: Stereotypic and psychomotor agitation

Attitude: Excited

Mood: Tension, Labile

Progression of thought: Remming, incohorence

Impairment:

Patient cant do the job

Impairment of social function


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Differential Diagnosis

F20.1 Hebefrenic Schizophrenia

F20.2 Catatonic Schizophrenia


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Multiaxial Diagnosis

Axis I : F20.1 Hebephrenic Schizophrenia ,

Z91.1 Treatment adherence

Axis II : Z03.2 No axis II diagnosis

Axis III : No axis III diagnosis

Axis IV : Problem with his girlfriend

Axis V : GAF admission 50-41


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MANAGEMENT

Morning ReportTuesday, October 21st, 2014

l i


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Management Planning

Hospitalization

Patient has symptoms such as talk and laugh to himself

Patient wont perform a job

Drug adherence

Emergency Department Haloperidol 5mg im

Diazepam 5 mg iv

Wards

Haloperidol 5 mg po 2dd1

Psychotherapy

Response Remission Recovery


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R i i Ph


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Target therapy :

100% remission of symptom

Inpatient management

Haloperidol 5 mg 2 dd I

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

Remission Phase

R Ph


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Continue the medication, control topsychiatric

Rehabilitation:

- Help patient to find a hobby,

- Help patient to interact normally with his

family and neighbor- Family education

Recovery Phase


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Thank You!Tuesday, October 21st, 2014

morning report psikiatri

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