Morning Report 17 September
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Transcript of Morning Report 17 September
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MORNING REPORTSupervisor : dr. Sabar P. Siregar, Sp.KJ
Wednesday night shift,Wednesday night shift, 1717hh September 2014 September 2014
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Patient Identity
•Name : Mr S•Sex : Male•Age : 45 years old•Address : Magelang•Occupation : Unemployed•Marital State : Divorced•Education : Junior High School
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RELATIVES IDENTITY
• Name : Mrs. Nn• Sex : Female• Age : 42 years old• Relation : Younger sister
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Reason patient was brought to emergency room
Patient had symptoms of uncontrolled anger, rampage, talking and laughing for unknown
reasons since a week ago
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Stressor
His mother didn’t give money
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Present History
After dischargefrom RSJS 2 months ago with similar symptoms, he
didn’t go to RSJS for therapy. He also didn’t take the medicines
regularly.
After dischargefrom RSJS 2 months ago with similar symptoms, he
didn’t go to RSJS for therapy. He also didn’t take the medicines
regularly.
• He had decreased appetite, talking and laughing non-sense. He was still able to
socialize and do daily activities.
• He had decreased appetite, talking and laughing non-sense. He was still able to
socialize and do daily activities.
2 months ago
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Present History
Uncontrolled anger,rampage, more talking and laughing
for unknown reasons.Patient was said to have stop taking
drugs.
Uncontrolled anger,rampage, more talking and laughing
for unknown reasons.Patient was said to have stop taking
drugs.
• He was not able to do daily activities and had difficulty in sleep. He didn’t
socialize with others and still had decreased appetite
• He was not able to do daily activities and had difficulty in sleep. He didn’t
socialize with others and still had decreased appetite
A week ago
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PSYCHIATRIC HISTORY
He had been hospitalized for 3 times since 4 years ago
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Day of Admission17th September 2014
Patient was brought because of:• Uncontrolled anger• Rampage•More talking and laughing for unknown reasons•Patient was said to have stop taking drugs.
Brought to hospital by the sister
• He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased
appetite
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EARLY CHILDHOOD PHASE (0-3 YEARS OLD)EARLY CHILDHOOD PHASE (0-3 YEARS OLD)Psychomotoric (No Valid Data)- there were no valid data on which age patient
• 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)
Psychomotoric (No Valid Data)- there were no valid data on which age patient
• 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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Communication (NO VALID DATA) - there were no valid data on when patient started bubbling. (6-9 months)
Emotion (NO VALID DATA)- there were no valid data of patient’s reaction when 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 follow objects,
recognizing his mother, recognize his family members.- there were no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.
Communication (NO VALID DATA) - there were no valid data on when patient started bubbling. (6-9 months)
Emotion (NO VALID DATA)- there were no valid data of patient’s reaction when 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 follow objects,
recognizing his mother, recognize his family members.- there were no valid data on when the patient first copied sounds that
were heard, or understanding simple orders.
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INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)INTERMEDIATE CHILDHOOD (3-11 YEARS OLD)
Psychomotor (NO VALID DATA) 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 regarding patient psychosocial.
CommunicationNo valid data regarding patient ability to make friends at school and
how many friends patient have during his school period.
Emotional (NO VALID DATA)No valid data on patient’s emotional.
CognitivePatient was one class backward at 2nd standard of elementary school.
Psychomotor (NO VALID DATA) 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 regarding patient psychosocial.
CommunicationNo valid data regarding patient ability to make friends at school and
how many friends patient have during his school period.
Emotional (NO VALID DATA)No valid data on patient’s emotional.
CognitivePatient was one class backward at 2nd standard of elementary school.
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LATE CHILDHOOD & TEENAGE PHASELATE CHILDHOOD & TEENAGE PHASE
Sexual development signs & activity No valid data on patient’s sexual development
PsychomotorNo data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.
Psychosocial No valid data regarding patient psychosocial.
Emotional historyNo valid data on patient’s emotional history.
CommunicationNo valid data regarding patient ability to make friends at school and how
many friends patient have during his school period.
Sexual development signs & activity No valid data on patient’s sexual development
PsychomotorNo data if patient had any favourite hobbies or games, if patient involved in
any kind of sports.
Psychosocial No valid data regarding patient psychosocial.
Emotional historyNo valid data on patient’s emotional history.
CommunicationNo valid data regarding patient ability to make friends at school and how
many friends patient have during his school period.
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ADULTHOOD
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Erikson’s 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 1st child of 2 siblings.•There is no psychiatry disorder in family history.
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Genogram
Female
Male
Dead
Patient Live in one house
Divorced
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PSYCHOSEXUAL HISTORY
Patient realizes that he is male, and has interests to female. His attitude is appropriate as a male.
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Progression of Disorder
Symptom
Role Function
July, 2014 NowAugust, 20132010
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Mental State 17th September 2014
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BEHAVIOUR
•Hypoactive•Hyperactive•Echopraxia•Catatonia•Active negativism•Cataplexy•Streotypy•Mannerism•Automatism•Bizarre
•Command automatism•Mutism•Acathysia•Tic•Somnabulism•Psychomotor agitation•Compulsive•Ataxia•Mimicry•Aggresive•Impulsive•Abulia
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ATTITUDE
• Non cooperative• Indifferent• Apathy• Tension• Dependent• Passive
•Infantile•Distrust•Labile•Rigid•Passive negativism•Catalepsy•Cerea flexibility•Excited
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Emotion
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Disturbance of Perception
Depersonalization (-) Derealization (-)
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Thought Progression
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Content of Thought
• Idea of Reference
• Idea of Guilt
• Preoccupation
• Obsession
• 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
•Non Realistic•Dereistic•Autistic•Cannot be evaluated
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Sensorium and Cognition
Level of education : Junior high school General knowledge : not assessed Orientation of time : Good Orientations of place : Good Orientations of people : Good Orientations of situation : Good Working/short/long memory: Not assessed Writing and reading skills: Not assessed Visuospatial : Not accessed Abstract thinking : Not accessed Ability to self care : Poor
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Physical State
Consciousnes : compos mentisVital sign :◦Blood pressure : 110/70 mmHg◦Pulse rate : 86 x/mnt◦Temperature : 36.7◦RR : 18 x/mnt
Consciousnes : compos mentisVital sign :◦Blood pressure : 110/70 mmHg◦Pulse rate : 86 x/mnt◦Temperature : 36.7◦RR : 18 x/mnt
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Review System Head : Normocephali, mouth deviation (-)
Eyes : Anemic (-), icteric (-),
Neck : No rigidity, no palpable lymph nodes
Thorax :
Cor : S1-S2 reguler, murmur (-)
Lung : Vesicular sound, wheezing -/-, ronchi-/-
Abdomen : Pain (-) , normal peristaltic sound,
Extremity : Warm ,capillary refill tine <2”, edema (-)
Neurological exam : Not examined
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RESUME
• A man, 45 years old, appropriate according to his age, completely clothed, poor self care
• Reason to be brought to hospital were Uncontrolled anger, rampage, more talking and laughing for unknown reasons. Patient was said to have stop taking drugs.
• He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite
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Mental Status Impairment
-Mood: dysphoric
- Perception: auditoric hallucination (+)
-Content of Thought : idea of guilt, delusion of persecution
- Form of thought: non-realistic
- Impaired insight
• Uncontrolled anger
• Rampage • More talking
and laughing for unknown reasons
He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite
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Differential Diagnosis
F20.0 Paranoid Schizophrenia
F25.2 Schizoaffective mixed-state type
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Multiaxial Diagnosis
Axis I : F20.0 Paranoid Schizophrenia Z91.1 Discontinuation of
medicationAxis II : Z03.2 No diagnosisAxis III : No diagnosisAxis IV : Problems with the primary support
group (family)Axis V : GAF on admission 30-21
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PLANNING MANAGEMENTPLANNING MANAGEMENTPLANNING MANAGEMENTPLANNING MANAGEMENT
Inpatient (hospitalization)• Patients had Uncontrolled anger, rampage,
more talking and laughing for unknown reasons. He was not able to do daily activities and had difficulty in sleep. He didn’t socialize with others and still had decreased appetite since 1 week ago.
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RESPONSE PHASERESPONSE PHASERESPONSE PHASERESPONSE PHASE
Target therapy : 50% decrease of symptoms
Emergency departmentHaloperidol 5mg i.mDiazepam 10 mg i.v (sedative and muscle relaxant effects)MaintanceHaloperidol 2x5mg
Re-assess patient
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REMISSION PHASEREMISSION PHASEREMISSION PHASEREMISSION PHASE
Target therapy : 100% remission of symptom
Inpatient managementContinue pharmacotherapy: Haloperidol 2x5mgImproving the patient quality of life : Teach patient about his social & environment(interact with his relatives, socialize with his neighbors, get a new job, find a hobby to do his spare time)
Outpatient management1.Pharmacotherapy : Haloperidol 2x5mg2.Psychosocial therapy
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RECOVERY PHASERECOVERY PHASERECOVERY PHASERECOVERY PHASE
Target therapy : 100% remission of symptom within 1 year.
- 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 :-Explain to his family about patient’s mental disorder and his treatment.-Educate his family to support not to exile the patient.-Ask his family to monitor patient’s progress and make sure the patient takes medicine as prescribed.
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THANKYOU